GW1-2022-09335_Well Construction - GW1_20221007

W BLL CONSTRUCTION YtI;CORD
This form can 6c lucd for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information: C
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14.WATERTONES
Weltt.ontractorNarm FROM 'ro DESCRIPtION
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NC well Contractor CertificationNumber r7 l7 ft 5 Z it i V
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15 d11TER.Ci1S11a1G fortuoi - �idh RiZ liextitt
earnGtte Well ®rell"ing, Inca FROM 1Yl DLultert+�a rrcrcwvEss
ft j /y ►HA fBRiAL
CoagianyName l/bl i DIHGftI ClNZ
tC2 Well Construction permit / 41/ FROM G•OIZTOCB IN( w bieni.
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DIAMEtTH
Lis'all applicable Krll construction permtls(it many Srmq Foriance,,.,c ft R
. �1arcENE� MATERiA[
10.
3.Well Use(check well use): ft
Water Supply Well: 7T:SCREEN:`
FROM TO DIAMETER SLOYSIZE
❑ ❑M icipal/Pahlic• it TBICR[vFSS MATERIAL
ft ia.
❑Geothermal(,ieating/Cooling Supply) rsidentia!Water Supply(single}
R it in
❑industrial/Commercial ❑Residential Water Supply(shared)
PP y( ared) 1 OOi1T'•'..
❑iai ation FROM TO 6tATERIAI. -'
Non-Water Supply Well. ft EMPLAC2MFM MEIHOD'hAMO[1t17
ft §and/ our
❑Monitoring [Went
❑Recovery ft ft
injection WetG (A7-,1(
❑Aquifer Recharge ft ft
❑Grourrdivater)Zerriediation ?19t'SAlYD/G12ACi;:PrsCXC i#: :liCstile
❑Aquifer Storage and Recovery ❑Salinity Barrier RROM To
❑Aquifer Test MATERIAL EMPuceitiwrMersoA
❑Stormwatcr-Drainage it R
C7E�gierimental Technology ❑Subsidence Control it ft
❑Geothetmal(Closed Loop) ❑Tracer :,ZObRYi LiAi t OG:aitiicli: ddiiiduiil'•sltee}s:itntcess8
❑Creothermal{Ileating/Cooling Rehrm) FROM TO D PnaN eoler h=dn❑Other zoiraek{explain under#2•I Remarks /(� tt Z ft V :'n+ize der
4.Date Will(s)Com feted 7 � we1D# Zft
52.Well Location: 0>5- R R { 5 n C
Sr�MML► �-�a,)1e-,ki5 90 ft 6� ft J
Facility/Owner c S r s
[F�acilit EW(ifipplic W) Ft
O (%' l t�,!�( l l y ft —
Physi�al Address,City.an Zip `�� ft ft t .1
i'amel T entifica=No.(PIN)
5b.Latitude and Longitude in idegreedminuteslsecondsur decimal aegrtxS:
(W-4 field,one lallong is sumcent)
6 ?.2.Cerhficatibie:
// - W C97%�f/
6.15{arc)the wsll(s): L 0P .anent. or OTemporaiy SiS eofcettifiet)well Canttatxor — Da
8y sr ming this form,t hereby curify thm the weUfs)was(were)constructed in accordance
7.TS this•a repair to an existing.well: ❑YeS o[ o with I3A_NC4C 02C.0100 ar PIANCAC 02C.0200 iFd!If this it a repalrhpoutbrown well constrrrelitm iaformalion toil esploia the npurre•ojt6e 'NPY-ofthls reeordharbeenprovlded to the Well owner. Ctircrlhlc0on Standardsturd that a
repairrrader f21 renwrkr section or on the boekof i1rIS form.
23.Sitb'diagi�m or additibtialwell details:
&,Number ofwells constructed: You may,US6 tie liatk of this page to provide additionFOral well,site details or well
Subml mrrnefeiyecrionornon-rvarer cohsapplywellsONLYwithlliestuMc0=&Ucfiarr,youcan tondetar7s. Youmayalso.aliachadditionalpages:ifnecessar .
subroaeform. '
,tU S1 OMMALINSTUGTIONS
9.Total well depth below land sorfaCc. l�j
FormnCW' c ellslicalldepMsrjd$ererrt(ecmrrple-3f-Z00'and2 00 (;t) tea-For Ai,V, e7,F Submit this&III within 30 days of completion of well
n _ constiuetion foffic fdllowing:
10.Static/is a6 level below top of casing: 0�5 (ft) Division of W9tcr Quality,Information Processing Unit,
If>'arer level is above easing,use"+"
1617 Mal Service Center,Raleigh,ITC 27699-1617
1L Borehole diameter: 346.For inreetion.V &.' in addition to sending the fort to the address in 24a
Cn'•)
12.Well coustruction method:_ �;v �(p�G above,also submit a copy of this form within 30 days of completion of well
(i.c auger;rotary,cable,dheet pustr,ere,) ----r CO btion to ttie following.
FOR WATER SUP LY WELLS ONLY 1 11[visiou•of Water Quality,Underground Injection Control Program,
163611 MI Service Center,Raleigh,NC 27699-106
13a.Yield(gpm) Method oftest: BIOw1120 MinUte 24r_Fok-Water.Sunnly gt Iniection Wilts In addition to sending the form to 2 C tha addresses)above,also submit one(cdpy of this foim within 30 days of
13b.Disinfection type: Amount:_ 1 UP coinphYion of wc11 construction to the i ounty health deptutment of the county
where constructed.
Fnrm Gwa i
North Carolina Department of Environment and Natural Resaurws—D,x Won of water Quality P
Revised Jan.2013