GW1-2022-09113_Well Construction - GW1_20220926

Jan. 29. 2018 10:58AM Env. Health . No. 6711 P. 1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.W 1 Caotracto IutotTnatio
--•tee .. FROM TO DESCIIIPTiOW
Well Contractor Name g,
NC ell coaaac or Certification Number (djgU7 ►gly(}: >iaoltfegf"." ':OIt f '' Mb "y �r`Ma?'""
i FROM TO DIAM6T R Tti[CItNF59 h1A
(� e a rt. n - V u
Co a :: .�.�._... ..
16s`INNERICA }OR'rlfni[wC►: II�Cmtot;Josfd moo' +.�+. � e":rtr-t..=:-
L Well Construction Permit#. J y `j f o FROM TO 01AM93e 't MCRN s9 MATERIAL
Ust at/applicable wen maimmton perDrat It e.UrC,County,Stott,Yariante,en) tr• tr. i In.
3.Well Un(cheek Well Age):
Water Supply Well! FROV. TO I DIAMETER F LOTS= THICKNESS--MATFArAL
_Agricultural QMunt'cipal/Pablic 0 D. If. io.
Geothermal(Renting/Cooling Supply) i deetial Water Supply(single) R. tR in. -
_InduatrieUCommcreiol DResideattal Water Supply(shared)
Irriantion FROM T , MATERIAIL UVIACIUMENTMErROD&AMOUNT
iVon•Watop Supply Well G n. �N
Monitoring ❑Recovery R. ft.
Injection Well:
- AquifefRecherge 043rundwaterRemediation -- -r•
79��ilZ?D1GRi1tBIiPACK' Fai" Dle'��+•s_,�_:._,,:;,�::",.� ,,.,T,,.;•..:.;..:;;._;,
10cofAquifer Storage and Recovery OSaliniry Barrier I TO MATERIAL EMPrACAMENr ETIIOD
fiennat
Aquifet-Test 'nStonnwaterDrainageExperimental Technology Subsidence ControlGeothermal(Closed Loop)_ OTraeer FROM TO eatirig/CAo�rng Return Other lain under N21 Remarks R, G R C/G
4.Data Well(s)Completed:9 i—>).2 Well 101 n R a
Sa.Well Loo/caliom �Q R h or —
Fam'litylOwnet Name
y� FaciilityIDB(ifcpplicable) rt a .
Physical Addmis,City,add Zip / rt� rt• —
Couoty ParrelIdemificatiaa NO.(PIN)
Sb.Latitude and loDBitnde in degreedminutedieconds or decimal degrees: Q
(ifwell Add.one Itillang is sufficient) l 22.CertiGcalian: d /�
)S'a?t G 7 90N l`'�� ��Llo w „t
6.Is(are)The wefl(s) Permanent or Tempory 4igmnut o ertified Well Connsetor Date
By sigrdng dui/brat I hereby coy*Thar the imll(t)oar(1rero)esu mend eh accordance
7.Is this a repair to an alsting well:
ra
QYes art No with ISAWCAC 0IC.0100 or IJA NCAC 02C.0200 Well Conanwilan Smedontr and that a
((this Is a r9ain fiff mrt Ana w,welt goatrnzvot,inf&wtian mid&&M the nai m►of the copy of this amid has been pm tided to the mrell owner.
mpa:runder 1121 renmrle section br an the backgfthtsfarm- 23.Site diagram or additional well details:
8.For GeoprobtMPT 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 l GW 1 is needed. Indicate TOTAL,NUMBER of wells construction details, You may also attach additlonsl pages if neeess+iry.
drilled: /
SUBMITTAL It4STRUCTIONS
9.Total well depth below had surface. L� (h.) 24a, For All Well Submit this form within 30 days of completion of well
Fo>tnvtaple wdys Gstat]deptht iJdifferenr(esba�ple.3(dfz00'and z®!00) construction to the following:
10.Static water level below top of casing: d C (R) Division of Water Resources,Informallon Processtug Unit,
Ifwarer level ft above tmvig we"+^ 1617 Mail Service Cehfer,Raleigh,NC 27699-1617
It Borehole dmmeter. (In.) 24L For Injection Wells: In addition to sending the fanrt4o the address in 24a
(� above,also submit one copy of this tbmr within 30 days of completion of wall
l2.Wei[construction method: r) construction to the following
(Lc.aagcr.rotary.cable.&=I push etc.) -
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Harz Service Centel',Raleigh,NC 276994636
t
13s.Yield(glim) Method of test: �. 24c.For Water 3unDly&Inlecdon Wells: In addition to sending the form to
the addresses)above, also submit one copy of this form within 30 days of
131LDisinfection type: �Il Amouai: � �t��7 completion of well consnorion,to the county health department of the county
where constructed.
Form GW-1 Nonh C=Ihm Depanmeat of fmriromneanl Quality-Division of Wattf RcsomM Revised 2-22-2016'
i •