GW1-2022-08836_Well Construction - GW1_20220912

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BJ•CO1aISLIUC 'D1V RMORD Id'aW-11' For Internal Use'Only: -
s �I _�Yr:'a`Ga`ntraeror lnformatioh; , _
(f—m"e ;S tiovl-e 114.WATER ZONES
Well CwhactosName FROM TO ,D9SmneilON - - - ;I IA f6 lib a _J G,e -
w � - G
NC well Contractor Cetti&-tiaa Number E A S ft S Let•
- - LS.OUTERCABE'IG for could-nrednvrEs)OALINER de Grable
YADICN WELL COMPANY,,1NC. .aaoM -,m_ - -nlAb>Pt•Ett 'TRImOiPSs MATEIQ
CompaayName 16,Ral tCAIMGORTUMG tLermilclosed-loo -
2.wr�Construction
o ar x el nn Per m o#:14JS Mr- QS� 1�1�7 3� �y - T�cta�ass MerRau7 jA/ 3 2 FimM m nuasimt
. YP _ _ _.- P (..WC,Caunty,
-
-,3:Well Tise.(cheekwdluse): _
- -- - 27.SCREEN
Water Supply Well: -
P1lOM TO - - -,DIAMRCER RIATbTLE 7HIe1QiFS5 MATERIAL
l 'culbnal _ ni ' el(Public
- R t_t 1Iv..i QAtpI _ /Elmu• pP
t,
. .DGeothemle](fleatin7�Cooliag Supply) tnResidemle]Watrs Supply(single) ' -
Oladnet.ial/Commercial OResideatial Water Supply(shared) '10.GROUT _ -_ ,,EMer.ACEtvrQfTMareoa AMOUNT
FROM I TO �
OlQi 'on OWells>'100,000.GPD
Non-Water Supply Well —_ b It "L 'ea. � _-.
i� k
y aMoaimxing
.. 'Injection Well: - — - - _ _ _ -
Ec ift. _
'l3Aquifer:Rechmgo OGroundwater Remediatioa -
19.SANDIGRAVEL"do lirahie
j; aAgmfer Storage and Recovery llsalh*Banier FROM _ _ :'. -yn, _ ' .MATERUL EMPLACEbmrrrMETnOD--
pAgaifa Test OStoamwaterDminago
ft. -. ft
ExP gy - _---- - - ---- - - -
❑ er�eental Teehaiilo OSubsrdenrz'.CoDhvl � �, ,
DGeotharmal(Closed Loop) OTracer 20.DRILL7NGL09ali2ehndditiozWsbmtsifnicmre - - -
- FnOM. TO ='.DL9m{IPIION ialar soSVmeY eG
OGeotiremral(HeaDog/Coa]ingRehuo)__Ootherl(explaintmae#21 Remrms)',
' pp� -
4.DateWr�(s)Completed:, � 'ZZR'ell IDt /`3W�-_ . 315 R
Tl 4 - - -
' Sa.WellLocation. 37 , ?5 fl. - 5 R f+..„'fie_ G.•.�C.
,►d
- Phone#� n.
4uaer�l r._ 3alr e ) 2 3 371 ..., G.. VA.
R ft
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FecOrty Fomlip•]D$ ¢ le
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i , PhysicalAddxrs ,sad r R T.
VO4kir. ':>'REnrABxB - 9D
Cnmty -. Pmcel lde¢fiticatiaa No:[PIIi) In —i-n r �t UnO. /\
' ifwell feel one lmrlongn mffieleai) _ grass:
(b.Laht�eendiloa audein,de eeshaiauteslsewade,orderimalde -_,21.Certific-tian:6Js . 1
N .
' are thee W s�3,ermanent o o �?
as
( ) - () pli< _ emporary S- ofCc6sed weueav7aomr- _ .Date
BY31V*+9thisform,!hereby certYyfhaf the well(s)war(were)c=rhucfedfn aconlancewilh
7.Is this a repair to in ecistingwell: 13Yes or If4Vo '15A'NCdC 02C 0160 or 15A NCSC 02C.0760 Well Cunstruaron B m Amlr and that a COPY
} jfprtr is arWafr fill outlmawn wellcnrortedon Womaflon mdmplam the nature of Me cfthl+record has bemprmfdedla the well owner.
.repa/rrmder$2l�remmkrseetfon or on Me bvckofiffGfarm.
- 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Gcothermat Wells having the same You may use the hack of iivs pap to provide additional well construction ioib
eoushumon,only1OW--1y�'s needed Indicate TOTAL NUNMERofweds (add-See OvePm Remed:aSox):You may also effioh eddmopal pages D:`aecessary.
drilled• '/ -. - 24.SUBNUTTALINSTRUCTIONS
'9.Total well depth below land surface: -� � _ 'vo Submit this GW-1 within 30 days of Well completion pw the following:
Formultrple wells list alldepths lfdfsszeff(ermnple•3Q200'ond2@lG0j
'10.5tatiewater level below top of casing:-_.. So (ft) 24a. For All Wells: Original farm to Division of Water Resources (I)WR),.
rfwaterhvet is above casing vre"+" - - --- Pm 'on Processing Unit 1617 MSGReleigh,NC.2T699-1617
p hiformah
'J ) Bit Off: Lr O g.L 2db.ForIziectiomWells: Copy to D Uu
ILBoreholediameter: (in- __ WR,;- detgrmmdlnjection Control,.(NC)
Program.1636 MSC,Raleigh,ANC 27699-1636
iiWell'construction method: AIR ROTARY _
(' cable,dicat eta. - -- county
Waterentaln.aad departmennGececounty ReturnV Iled:,Copytotbe
>_a sage,rotary, pusb, ) covmy environmental health deperlmearofthe county Where iastelled:
FOR WATERSUPPLY WELLS ONLY,_-- FemiitPro 1611 MSCduda over�100 000 GPD' Co to D
24d.For Water Wells 7o Copy Wit,�CCPCUA
A P gsmq ;Raleigh,NC27 99-1611 ��;
L3a.Yrdd.(gpm) '
70%HTH I O2 'DATESITEVISITED:.�j /�—ZZ
13b.Drsrnfection type: Amount: I a - -
n�-. ... /' 4R• ?: `.IY .2P �[.� - - VISITED'.BY: