GW1-2022-08352_Well Construction - GW1_20220829

WELL CONSTRUCTION RECORD(GW 1) For Internal Use t]n(y:
I.Well ContractorMormatiou:
D© I.,.-N Q��yam, 14.WATERZOM
Well CanttactorName FROM TO 1lR4dBMON
3 O Z�f-A �M
NC Well Conti—b.C-68—e—M
• r
oPa-4st' W 1 ; r !/' s 1 Pl FROM TO D TIUCHNE38 MATIMM
Company Nana d
16.MOM CASgIGOR 11MG thcaualclosed-1
2.Well Construction Permit: '1 71�rk) �,/��2�1 FROM To I DrAPART B I =CRNMM MATSUAL .
Lest art applicable well canslt wdoapmdrs(i.&MC,Camay,State,Variance,ell") • L �•
3.Well Use(che*vveH use): ft.
WaterSDpply Well: 1T,sCREENl
FROM SLae cga>�as ivtttnRtnt
Agricultural �MunicipaUFubiio 1? ft & Lm
Geothermal(I3eating/Cooling Supply) ffilf fdentid Water Supply(single)
Industrial/Commercial DResidential Water Supply(sbared) IS GROiIT
11nigation, FROM I TO WATERTAL EMPLACE ENTMEMOD&AMOt1NT
Non-Water SWly Well: �' ft- �� •�
Monitoringps—
covew EL
1wec[ion Went
ft.
AquiferRecbmV D(rolmdwaterRemediadoa
-- ft.
1 .SAMIGRAVELPACK if Ileah AqulfSMMVandR=ymy
To NtAT MAL ENMACsaMrrrnns 5
Aquifer Test EISMrm:waterDrainage ft. it
Experimental Technology DSubsidmw Comrol fa R
Qeothermal(Closed Loop) Tracer 2u.DRIIMGLOG attaeh additional sheefst
t3eothenml eatitlg/CoolingRetum. Other( Iainunderg2lRemaAm) 1yR°M TO tyssCauz[oN Dolor aorvoac stately
ft. &
4.Date Weil(s)Completed:?27-� reII ID ft- ft.
5a.WeIl Location• ft'
R / Ct. it. ...
ed dDo/ I4Oyhtc
FadUtt/ylt}wnerNamell, /��/ / J� F/acilityID#J/(ifapplicable) ft. a ri
�D2 /Y /V[ 1�.2_I7r] Y./kr(�f/LQTUT fG y,t. II
a Kam.F.
�' i
AhysicalAddress.t3p,anrlTp I ft. R.
/J 21.RLd ARES .+
WAY - PasatldeatificatirmNo(PIl3} `� ,, _
Sb.Latitude and longitude is D QIs�
ng degreeslmittnteslsecaads or degrees:
ofwell field.one Iavlong is sufficient) 22.Certification:
6.13(ane)thewell(s) -einment or Temporary ftdrate rtified ell 8sclor Date
Sy signing thrsfarm,I hereby eolify Star the we4s)was(were}cmunueted In arcwtwEe
7.Is this a repair to an ezdsGmgwell: MYes or @1fi Writ ISANCAC 02C.0I00 ar.1MMAC 02C Moo WcU ConstrucdonStandards and tharo
lfrhlsisarepatr,jiltoutlUiownweticonmucttoninfartnationatulespTatnthetwArteofthe copy ofdtlsmcvrdhasbunprvvidedladwwuUmwzer.
repab'underd21 remarissedlonaron the backofd sform.
:3.Site diagram as additioaW well details+
S.For Geoprohe/DPT or Qosed-Loop Geothermal Wells having the same You fray use the bad:of this page to provide additional well site deWs.or well
construction,only 1 GW-1 is needed, indicate TOTAL NUMBER of wells construction deti ils..Yoo tnay also attach additional pages if necessary.
drilled: SMINIFTTAL INC mrcrIONS
9.Total well depth below Land surface: 00 24E6 For All Wells: Submit this fora within 30 days of completion of well
Formuldple wells list aUdepths ifdWwant(e=rp1e-3@200,and2@100) consttuctiontothe fbHowing:
10.Statfe water level below top of easing: 2 (f0 Division of Water Resources,Information Processing Unit;
IjwarerTeve!h above oasbrg,use"a-"
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (Oyu I(in) 24b.For i tection Wellst In addition to sending the form to the address is 24a
12.Wellco»strnciion method: it.r above,8150 submit one copy of this form within 30 days of completion of well
(Le auger?mtaq,rabic~du=tpasl,eta.) � ConShuCii0nt0 the foIlOwing
FOR WATER MLY WELM ONLY: Dlv7slon of WaterResoamm,Underground lNecHon Control pn,Vmm,
fQ6 Mai!SOLTICc Venter,lW*,L,NC 2769NUM
13a.Yield Wra) S Method of'test klsr Water Snarly&TnLOLIM Wells: In addition to sending the form to
the address(es) above also submit one copy of this form within 30 days of
13b.Disinfectlon type: Amok completion of well construction to the county health
YA=Constructed �pariment of the county
FormGW-1 Worth Cacti=DapameatofEnvimamentalQuality-Divlaimof'WaterRowasm RwAsed2 7L2016