GW1-2022-08964_Well Construction - GW1_20220919

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WELL CONSTRUCTION RECORD(GW 11 For Internal Use Only:
1.Well Contractor Information:
WellComractroName FROM TO DESCRIPTION
ft. n.
NC Well Contractor CettificationN
r(7 FROM TO DIAMETER THICKNESS MATERIAL
llCompan` YName l 1t.�`�j a� fL 0 O ft. 6!�-hL ��pe-0 fC
2.Well Construction Permit ft 1 a© � "' ` FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,Stag Variance,eta) % ft' 1O
3.Well Use(checkwell use):
[No
SupplyWell: FROM TO DIAMEM' SLOTSI� THICI(NM MATERIAL
ultural tnicipal/Public ft. ft im,
ermal(lieattng/Cooling apply) CIResidential water Supply(ogle) ft. it.
trMCommercial DResidential water supply(shared)
Irrigation FROM TO MATERIAL E391LACEN EW METHOD&AMOUNT
ater SUP*wen: fk �c1 s+ ft. e0,'�Cl�� b a. Storing Recoveryft. ft,on weu: ft. it.
f �Gdormdwater Remediation
er Storage and Recovery 13Salln4Barrier FROM TOMATERIAL EMPLACEMENT METHOD
ferTest 13StormwaterDrainage &
rimental Technology DSubsidence Control ft. It:
ermal(Closed Loop) 13Trecer
ermal (Heating/Cooling Return Other lain Under#21 Remarks FROM TO DESCRIPTION color,hmlasg,wWrwk zmin shme da
4.Date Well(s)Completed: 6 ag 2�,We11 ID#
5 well Locadone G °� 9, 1-1`� ft 1 R' 0-`( WN
(� 2022 ft
Facility/ Name Facility ID#( le)
4 Mine
UC1 Se _
icalA�dd�re�sS�C�iriy,amiZip vu+vvuxt ,i i.:,::�wia%r9 iJni} ft. $
County Parcel Ideatificatim No.(PIN)
Sb.Latitude and longitude in degrees/minutestsewnds or decimal degrees:
(ifwcU field,one lat/long is sufficient)
22.Certification:
- - 4 zP10-4�-- 6ht
6.Is(are)the well(s)ofermanent or Tempo;No
Signature of t ertified well Contractor
By signing this form,I hereby eerAify�that the xell(s)xns(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or with 15A NCAC 02Q.0100 or 15A NCAC 02C.0200 NeU Construction Standards and That a
Ifthis is a repair,fdl out knmva uvHcorwmxaan irfornwtion and esplain the narra a of the copy ofdds record has been provided to the well owner.
repair under#21 remark section or on the.back ofthisform.
23.Site diagram or additional well details:
8.For GeoprobeM.PT or Closed-Loop Geothermal Wells having the a You may use the back of this page to provide additional well site details or well
construction,only 1 GW 1 is needed Indicate TOTAL NUMBER of construction.details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total wen depth below land surface: 24a. For An Webs: Submit this form within 30 days of completion of well
For multiple wells list aU depths ifdiffereat(crumple-3(a)200'and 2®1000 conshuchon to the following.
10.Stade water level below top of casing: (M) Division of water Reoources,Information Processing Unit,
Ifxnter level is above casing;use"+"i I 1617 Mail Servlc�Center,Raleigh,NC 27699-1617
11.Borehole diameter: �D (ln.) 24b.For Infection WeIr. In addition to sending the form to the address in 24a
��- above,also submit.one copy ofji this form within 30 days of completion_of well
12.Well construction method: construction to the following.
(i.e.auger,mta:y.cable,direct pwb,etc.) �
Dhtlsion of water Resources„Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY. 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)' Method of test: t 24c.For Water Suaniv&Inlek tion Wells: In addition_to sending the form to
the address(cm) above, also submit one copy of this.form within 30 days of
13b.Disinfection type: y Amount: 7"a completion of well construction to the county health department of the county
where constructed
Form GW 1 North Carolina Depaz meat of Environmental Quality-Division of Water Resomie es Revised 2-22-2016

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