GW1-2022-07755_Well Construction - GW1_20220819

Jan. 29. 2018 10:58AM Env. Health No. 6111 R. 1
WELL CONSTRUCTION RECORD(GW 1� For Internal Use Only: ,
1.W 1 Contracts Iutormatio : I _
WCD ContactorNamc o aROM TO Dt�LRnTfON :"
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NC Well Coma&r Gnificatien Number °°?lS.011TEIC YSINCi:fui<malii'"e3 M. .OItI71iER B bib to
FROM TO DIAMETER THIMERS 1N11TER4U.
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2.Well Construction Permit i}. O TO oU Mfi THtCrcam WAVER AL
Liar nil eppllwbre—fl emuwerioapennt (1 e. C.Carony.Auto.Yonance,ere.) R. ft. In.
3.WeII Use(check well use):
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I
Supply en: .__-FRQH YO D Erna SLOTSIZE Tn MATERIAL
Dlturd [� tcipallpablie 0 R. R io.hermal(Reatindcooling Supply) idential Water Supply(single) R. RshwCommcmiol Residential Water Supply(sharod)lion FROM TO ATESIAL DU ACPa19MMCni & MOr1Nrater supply WeIINtYVA ix,
itoring Recovery R. rL
on Well:ifer Recharge []Groundwater ltemedietionP.Y£crSWragcandRecwcry DSalinityDenier FROM TO MATERIAL&rTest -0Stormwater Drainage n ft.rimental Technology Subsidence Control D. R.
ermal Closed Lou E)Traeerhermal(fieatitrg/Ca""I.— enun Other loin under-821 Rem],i, FROM TO orscaoPrmN tor,bndnrQ.wlVrak see tlr
1 CT fR tt Ce C-(a
4.Date Well(s)Completed: r, a WeIl1Dq o a % ij i oAr r -C
5a.Well Location: O d 2 y h /. ✓ /�` e—
lur`l� Kvelua.l ti rc rt
Faa7itylOwnerName FacdityM9(itipplicabra) rt
1 V a( AUG 1 9 2OZZ
phpicat Addrme,Cttp,add tip �— m rL
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Comm P,melyde"aniaoNa.(PIN)
5b.Latitude and longitude in degreeb1minutedseconds or dedmal degrees:
(irwall Bold.77,-0-2%
is suffidem) 21 Certification:
3 s el " e.?o;e) W
6.b(are)the well(s)COPermanent or MTemporuy Srginttaeo cpified Well Contractolr Dale
By iijnia8 tlua forft 1 here6y unto rlmr the vdl(r)um f k m)cwunmud of oacotdoam
a 7.Is ibis a repair to an existing well: rj'�. or ON. with ISANCAC 02C.0100 or!JR NGC 02C.0200 Well Connnruton Staadattlt and that a
(frhislsarepah.JiffernlaroamwellConrtmWoniformaonmideeplam the nammofthe cePYof this mcotdimbeenpivifdMro the ivellmmtr.
repair undere2Imamrbrealonoronthe Me*ofArrfann. 23,Site diagramor additional well details:
8,For Geoprobe/DPT or Closed•Loop Geothermal Wells having the same You may use thi;back of I"page to provide additional welt site details or well
construction,only 1 GW 1 Is needed. Indicate TOTAL,NUMBER of wells Construction details.You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total Weil depth below land surface: > 7 G UQ 24a. For All Wel1rC Submit this focal wi0tut 30 days of completion of well
bbrmuGtple veal ltrre►1 deprh.,fd71nem(aample.3®200 and 2®!00) construction to the following:
10.Stafle rarer level below top of casing: (11.) Division of Water Resources,Information Processing Unit
lfHmer 18"1 MOM unit use'+ 1617,fait ScrvlcE Cchter,Raleigh,NC 27699-1617
11.Bonhole diameter�(in.)
/ 24h.For injection\Velir. to addition to stmdnrg the farm to the addrus in 24a
12.Well construction method.� 'fA Y'l above,also submit one copy of fhis fban Within 30 days of completion of well
(Le.augc,rosary,cable,di-1 pusb.cw) —• Construction to die following: i.
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center•,Raleigh,NC 276991636
c
13a.Yield(gpm) Method of test r u 24c.For Water Supply&injection Wclla: In addition to sending the form to
the addresses)above, also submit one copy of this fort within 30 days of
131n Disinfcetlon type: �!I Amount: y�y completion of well construction to the county health department of the county
whue Consitucted_
FamGW-1 Nov*Cm hmDcpurmeafaf6aommaeoa!Quality-DivisionofWatafusam es Revisod2-22-2016'