GW1-2022-08262_Well Construction - GW1_20220513

WELL CONSTRUCTION RECORD(GW-I) For Internal.Usc Only.
1.Well Gontractor:lalormatioo:
d' ,14:WA7'ERkZ0I\E8.
WetiGonuactorName
FROM TO.: DESCWPTION.
ft.
ANC Well Coatnmtor Certiticotion Number .
D ^�► 13.OLFIERCAvttYG'tor"tn`"ttlti�ased;}ireW ARItiTN£R to"'tleab}e;��,,
+Q./rlt t t'il 9,(-A&-a t.J. FROit TO DIAMLTM TMCKNFSS MATE/WAL
CompanyNeme # let 11" v fL in SG/1k`� PVL
16,DMMER.CASFNG;ORITill1iFNGI. 6iiii usol los"edi"_ * .. .x'
2.Well Construction Permit# � b. 1 64� 2,1 FROM TO DIAMETER TIRCKNESS MATERIAL
un
List all applicable well construction pa7uits C.e.UIC,County,Statq Variance,etc.) ft. ft In.
3.Weil Use(check well use): rL tt En.
Water Supply Well- J1 SCREEN
FROM TO-- _ DIAMETER-, SLOTS17Z THIt70M MATEIr]AL.
OAgricultural OMunici al/public
p 1K 3 a n. 2- to ?�
13Geothermal(Hcaling/Cooling Supply) ,residential Water Supply(single)
ft ft ia.'.
DlndusLiaUCommetciai OResidential Water Supply(shared)Obri Lion OWc1s>100,0)OGPD FROM M
A :1^M
— TO
NE"171100 qQLOUNT
-- Nan-WattrSupplyWell:---------- --- — — -- rJ-- tt.-
OMankoring. ORecovery
Injection Well:
OAqufer Recharge ❑Groundwater Remediation
19.SAND/GRAVETst'ACK"
ClAquifer Storage and Recovery OSalinity Barrier FROM To MATtottAt MPIAC Aff"llASCnoll
OAquifer Test OStormwater Drainage p It. i�p f—
DExperimental Technology OSubsidence Control ft. ft
OGeothei nai(Closed Loop) OTracer 20.DRII;I iNG k:OG tittiich;i ddybiini111ii ti fuieraffisi' x:c +
l7Geo1herma] eating/Cooling Return) OOther(explain under#21 Remarks) FROM ft.. TO ft DFSGRTPrto!t color,hudat^saittrcrk a ere.
4.Date Wells)Completed: S i Well M9 R. fL
Sa.Well Location: ft n-
fL ft
RrjSQ i1I ...
Fituylbwtiet Nano Facility IDS(ifapplicable) R. tt
r cM�11 H ft
Ph C'ry and ft: rL 1 r•.
13
9D f
C Y ProCe
Pal ldentificatida No.(PIN) �>1l
Parcel 1410 -
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Ia11/long is sufficient)
C 22.Certifi tion:
6.Is(are)the well(s) eirrtanent or OTemporary Si ofCenifie c Contractor DWJr
ignh g this fount;I hera6y cmif that thewet/(s)Kws(were)constructed to accordance with
7.Is this a repair to an existing wells Oyes or -46 A NC
O2C.0t00 or)SA NCAC 02C.0200 Well Construction Standards and that a copy
Jf this it it repair,fill out Anse nrJl coast ruction Information ofxkwaja the nature ofthe of this rriord has been provided to the irell'osmer.
repair under S21 remarkt section or on the back of this fora.
23.Site diagram or additional we0tlelails:
S.For Geoptobe/Dff or Closed-Loop Geothermal Wells having the same You may use the back of this page io provide additional well construction info
construction,only.i GW-1 is needed. Indicate TOTAL NUMBER.of wells (add'See Over•in Remarks Box).Yon tiny also attach additional pages ifnecessary.
drilled:
24.SUBMITTAL INSTRUCTION
9 Total well depth below land surface: I
For multiple wellj Mist all deathr(fd(ocrent(rumple-3@200'a)nd 2@1001) (�) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing* / 24a. For All Wells: Original fotni to Division of Water Resources (D%%rR),
(-)" Information Processing Unit,1617 MS Raleigh,NC 27699-1617
lfn+utertle uaboveswing,use"+^ g t, C, gh,
11.Borehole diameter:_�_(in,) 24b.For lniection.Wells:Copy to DWR,Underground Injection Comm)(MC)
Program,1636 MSC,Raleigh,NC 21690-1636
12.Well construction method: MULL S�Q s j
(Lt.auger,rotary,mete,direct 24c,For Water Supply and Open-Loop Geothermal Return Welly.Copy io the
"�ere') county envuonmenta!health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: _ 24d.For Water Wells producing over 100,000 GPD:Copy to D)YR,CCPCUA
1 .Yield(gym) .,�79 D 4- od of test 12 PermrtProgram,1611 MSC,Raleigh;NC 27699-1 611
3a
i 13b.Disinfection 4W-1 r d r Amount: 6-2.
Foy t Noah Carolina Departme t of Environmental Quality-Division of Water Resources
Revised"Z019
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