GW1-2022-08582_Well Construction - GW1_20220428

Jan, 29. 2018 10:58AM Env. Health . No. 6711 P. 1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.�icoutra ero roformanq�� Ei- _x-.FROM TO 0ffiL'R17rtOlY
Wdl ContractorNamc 11
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NC Well Comae or Certification Number a 16 cQIlSElt t' Slblti'r6lrmTdtlrEiif -"'IIs:OB f•�"IifitMb 1
i FROM TO DIAMVFMa 7WHI IE33 MURAL
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1.Well Construction l'ermiM T� �
l ljt all applirnblt hell a morn ertot+pennln(l.a.U1C,Cowry Scare, oct13
ane#'err.) lo'
3.Well Use(check Hell use): R• tr. In.
WsterSa t r12:S Eft¢ :aX_
PP y►ye11: M TO I niANUER SLOTSI7E I THICKNESS MATERIAL
_Agricultural OMunicipaUPablic R. rt.
Geothermal(Aeating/Ceoling Supply) Residential Water Supply(single) ft. fL in:
_LtduatrieUCommcrcial ❑Resideatial Water Supply(shared)
'Irrigation FROM TO I MA rrL MPLACPMEMMEMOD&AMOUNT
'Non.Water Supply Won: Q R_ ft. , to
Monitoring ORecovery rt. ft.
Injection Well: A. n.
Aquifer Recharge OGmundxmter Remedietion _
Aquifer Storage and Recovery OS0linity Barrier FROM TO �CK MATERIAL ' - y sMPIAC>;ML'NrMMOU
_.AgviferT(sst -OStormwaterDainage R• rt'
Experimental Technology aSubsidence Control IL n•
Geothermal(Closed Loop), [)Tracer
2Q. I>KG.: .i aBr ed'dltionilrfiieirfti+e'caai'`.;_--
_Geothermal(Heatinp/CO'ojing Return (alter Minin under#21 Remarks) FROM To DfSCaltrrro: calor,hndnar,sol k :et err.
n C -e- ed C(o
4.Date Well(s)Completed: Well M# M rt'
Sa.Well Location, `�G IL l�U ft
Faelily/OwnefName Facil"..M(if opplicable) R' %
G
P6ys wd�,City,gad tip �7/
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Coaaty S Parcel Idemilicatioa No.(PIN) w ----
Sb.Latitude and longltode in degrcedmioutes/seconds or decimal degrees:
Crwall Md.rma ladla sufficient i. � > a�t7ttV17 J qT
n8�is ) 2Z.Certification:
6.b(are)the weff(s)OPermanent or OTemporary Sigm�riae o erifieit Well Connector j Data
By signing dusloret l hereby eatjy rhm'the iWffis)—(item)emuftwied eM acrotdoam
7.Is this R repair to an existing wetb OYez or C)No with 1 SANCAC 02C.0100 ar lJA NCAC 02C.020o Will Conrtnwlon Standahis and that a
((this Is a repot.,J1R old lnami waft eenstmetioh tnforlrrotion dird erplahr the,Wun of the copy of rhis awtd hot been prosrded to the ivell owner.
rep*tit*r tt21 namnls retAion 0r on the beet of iMsfarm.
23.Site diagram or additional well details:
8.For GeoprobeMPT or Closed-Loop Geothermal Wells having the some You may use the back of ibis page to provide additional well site details or well
construction,only I GW 1 is needed. Indicate TOTAL NUMBER of wcUs construction details.You may also attach additional pages if necessary.
drilled: (� SUBNJITTAL INSfR11CTIf N
9.Total treil depth below land surface: ! O (h•) 24a. For All Well Submit this form within 30 days of completion of well
For mdapk was/to all dap&Jdiffierent(trample.1@260,and I@100') construction to the following:
10.Static water level below top of casing: 42?--3 (ft.) Division of Water Resources,Information Processlug Unit,
Ifwmer love►u above embig use"*" 1617 Mail Service Center,Raleigh,NC 27699-1617
11 Borehole diameter. (Ill.) 24b.For Injection Wells: In addition to sendiug the form-to the address in 24a
\ 4Y, above,also submit one copy of this ibrm within 30 days of completion of well
12.Well construction.a method: construction to the following:
(.a aagv.rotwury,cable.
duvet pmT>,No.) -
Division of Water Resources,;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 106 Mail Service Cent&,Raleigh,NC 276994636
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13a.Yield(epm) ✓ Method of test: 24c.For Water Sooty&Injection Wells: In addition to sending the form to
the addresses) above, also subioit'one copy of this form within 30 days of
13b.Disinfection type: Amount: Cid J2 completion of well construction to the county health department of the county
where constructed.
Form Gar-1 North CmotimDcpanwot afEavimameaml Quality-Division of Water Rcsomees Revisod 2-2&2016