GW1-2022-08553_Well Construction - GW1_20220428

Jan. 29. 2018 10:58AM Env. Health No. 6111 P. 1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.W 1 ContrActo mra//rm''an //- /�
tl&-WAxf,2014IfS
FROM TO DES ION
Well Coll et rNamc
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52
NC Well ComeeTor Certification Number 13:;t)tkTER GiKSL�Iti♦' olrmid)rk8sid iv Its:OII y7NE1t Mob Rea bible. "F4_101',•„:
`C FROM I TO I DIAMETER T1I MES3 MATERIAL
fr. « do V
compaquima l 16 ER.CASIrYf:}OA'rdDiNG! •..-.":,�.�,...�T.:�•r.�:--,:
L Well Construction Permit a: GFROM I To I 01AMMA TBICKno MATERIAL
Us(all applicable wff cmurrr crion permits if.e.UIC.Comfy.Scare,Varionce.etc.) n• n• in.
3.Well Use(check wall use): n• n. tit.
Ater Supply Well: r1Z'StRtEtEbi:��^.s,�.•�.t�.�%�...�;a:;��.��_:�:�__T:�s^<._�.<:
Pply rRQN TO DIAMETER SOTS Tit[ KNEUS M TFRTAL
_Agricultural QMunicipaMblic D. n. m.
Geothermal(EkatindCooling Supply) idenGal Water Supply(single) n, lR m,
_InduatriaVCommtmCial ideatial Water Supply(shared} :ypx0>1T --==`-'""' _;' -' '`='"=- - �
lrti clan FROM i YREAM-RAERN&AMOUPU
i4on-Water Supply Well: n. Ir. 61 `IV
Monitoring ORecovery R R.
Injection Well: ft ft.
- Aquifer Recharge OGmundutater Remediation
79:SAND/GRiialBriPAC F.d"'lia'le _-+•_;.•'';-:i�.--:�•�•. ""'•'•..--.':>.-,-
Aquifer Storage and Recovery OSAlinityBflrtier FROM TO MATERIAL I EWPIACCMkTfrAIM011
_Aquifer Test E)StormWateTDrainage n tr.
Experimental Technology QSubsidence Control m n.
Geothermal(Closed Loop)._ QTraeer Fs0.:D G-1:6G eiiaV dWo)siiylieeisRirecitni
FROM To mescal roN«Iar,ne,dneu,sotYtoek
_ Geothermal(Reating/Cooling Remit Other(explain under#21 Remarks fr. O' ft. 4 L(
4.Date Well(s)Completed:Aa-�-Al Well JIM
Sx..Well Location: '-C
rLldG,llf�� t�LL.ISo h _ It ft.
Fleilitylownefmame Facility IDB(ifapplicable) R n'
2 it. ! ,
/ A 17
physical Address,City,add Zip -!EV/u s , C, An
(G II.
Coney Parcel Idenocatitm No.(PIN) go
Sb.Latitude and lotionlde In degreealmiauteafsecouds or decimal degrees: KIM,fwell field.one tarts m sufficient) � - 1'rr (9✓��
f tie' ) 22.Certification.
-3 366'999 N 6'a 3gf w QP
6.h(Are)Ibe wells) Permament or QTemporary Sigmnne o eai6ed WeU Connector ! Date
By signing ilds forom I herdby cer/gy it-the v dl(k car{here)emaniz red an occonbacs
7.Ia ibis a repair to an existing well; Yes or Wo with 114 XC.IC 02C.0100 or IJA NCdC 02C.0200 Will Connnwilon Slardoxlt and that a
(/this u a rrpair,)!!l ma tr,own we(!GOnttruetion h,forn,ati0n Qp +the nalaro of the copy of tMr f&vrd hm been provided io the irefJ owner.
repair under#21 renmrki ieerron or on dig had Of Ihtf fora,.
23.Site diaYram or additional rve11 details—
S.For Geoprobe/DPT or Closed.Loop Geotberatal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW 1 is needed. Indicate TOTAL,NUMBER of vVells eonsttuction details. You may also attach additional pages if necessary.
drilled: SUBNUTTAL INSTR11CTitZNS
9.Total well depth below land stlrfaces 0 (n•) 249. For All Wens Submit this form within 30 days of completion of Well
For mpinple wear tot arl depdu iild f/'stint(comple.1@200'and 2g100') coctsmrction to the following:
10.StAdc water levct below top of easing: .3"?— __(ft.) Division of Water Resources,Information Processing Unit,
11vardr level It above crafts We"+^ 1617 Mail Service Cchhr,Raleigh,NC 27699-1617
11,Borehole diameter. Y'd (In.) 24b.For Inleellon Wells: In addition to ictid ul;the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method. �� r construction to the following
(i.c.sgcr.,nttay.table,duet push,eto.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Matz Service Centti,Raleigh,NC 27699-1636
t
13e.Yield(eptn) Method of test. �. 24e.For Water Santily&Inleetton Wells: In addition to sending the form to
the addresses)above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to ft county health department of the county
where constructed.
FormGW-1 North CasetimDepartmeat afEav mmaeaml Quality-Division of Water Resources Revised 2-22-2016'