GW1-2022-08989_Well Construction - GW1_20220919

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WELL CONSTRUCTION RECORD(GW 11 For Internal Use Only:
1.wen Contractor Info n:
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Wc ContractorCertificationNafte,
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Company Name 2 �j `
2.Well Construction Permit#: a I ©� J f3 oM TO BLOW= xHICENESS MATEAUL
List all applicable well consbacdon permits(Le.VIC,Coa*,State,Variance,eta) % &.
3.Well Use(check well use): '
water Supply wen: HUM To DIAMETER SLOT SM TffiCKNffiti MATERIAL
Agricultural MueicipaUPuhlic ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential water Supply(single) & � his
Indushial/Commercial Residential water supply(shared)
Irrigation FROM TO TEMAL n OTA METHOD&AMO
-Non-Water Supply Well: a D to �> � Ot b
Monitoring Recovery S. ft. ? tN
Injection Well: k_F%`� y �,
Aquifer Recharge [,� "Remedistiaa
erStorageandRecovery Ds�PPdk cA 2022 FROM TO MATERIAL EMPLACEMENTMMOD
Aquifer Test. �Stomuwater Drainage '
ExperimenmlTeclmology QSu6stiCe��a �? ew Unit
Geothermal(Closed Loop) Tracer
Oi IL�r 6O
Geothermal Coolie Return) Other lain under#21 Remarks FROM TO DES ox actor twdn anal eta
4.Date Well(s)Completed: `a'� Well MN I Q B' �c�--►^
Sa.Well Location: tt. �'� e-d1 Ce
Faeitity/OwnerName - FaciilityIIVOfawksble) '
Physi Address,City,mid Zip it.tit. I ,
Own OD rvL� `'1 10 l *88"6 6 5
County ftcelWentfflcafionNo.(PlNJf
Sb.Latitude and longitude in degeeea/minales/aeconds or decimal degrees:
(ifwell field,ooe labbog is sufficient) O 2L C7! n:
35°�-o �a �' Q IZA-h-, g
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6.Is(are)tirc wells) erfwwt err �1'empoaary— Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to aD existing well:. E)Yes or No with IJA NCW 02C.0100 or 15ANCAC 02C.0100 WeU Construcdon Standards and that a
fak is a repai fill out brown well cm irucdan injornration and cW aln the nanoe ofdx copy ofdts—rd has beenproytded to the well owner.
Man"under#21 remarks section or on the back ofdis form
23.Site diagram or additional well details:
8.For GeoprobeM.PT or Closed-Loop Geothermal wells having the same 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 wells . construction details. You may also(attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS i
9.Total well depth below land surface: 24a.For An Wells: Submit this form within 30 days of completion of well
For multiple wells list aU depths tfdifferent(example-3@200'and 2Q1 M construction to the following:
10.Statie water level below top of (th:) Division of Water Resources,Information Processing Unit,
Ijxnter:leyel is above rve 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole dismeber: 24b.For Iniedim Wens: In addition to sending the form to the address in 24a
2.Well construction.method: VIC ,,,��( above,also submit one copy of this formwithin 30 days of completion of well
12.Well construction.method: construction to the following.
(i.e.auger,rotary.cable,direct push,etc
Division of water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: n 1636 Men Service de nter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of text >(� t 24c.For water Snnoly&Injection Wells: 1n addition to sending the form to
the address(es) above, also submit one copy of this.foffi within 30 days of
13b.Disinfection type: 7 Amount: d completion of well construction ter the county health department of the county
where constructed
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Form GW 1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016