GW1-2022-09627_Well Construction - GW1_20221021

WELL CONSTRUCTION RECORD(GW-1) For Internal Use only;
1.Well Contractor Information:
Oar ref f Paola I,* . 14..'-.WATE
ZO
Well&ntraclarNamo FROM I TO DEIS
MI5 L)5-A
NC Well Contractor Cortiffeation Number
----------- .......... "IN vornnuminged5volig
FROM I TO
I DIAMRTFR I THICKNESS I MATERIAL.
companyNaing 1 ft. JG G ft. 1%5 In- Z2VC
2.Well Construction Permit#:J1 91­0 1 FROM TO I DIAMPUR I THICKNESS MAW.RfAt.
lf$t all oppileable well consti7iciloilpei.n)lls(1.0,UIC,Coln
1111)1,State,Variance,1710) ft. ft.
3.Well Use(check-well use): ft. ft. In.
Water Supply Well: :'V;SC f
FROM Im I DIAMUER S1.0irsfyE I 1111CKNPss I NIATERFAL. J Agricultural DMunicipal/Public ft. ft._I_ I Ju.
Geothermal(Heating/Cooling supply) alkesidentlal Water Supply(single) ff, ft. In.
Industrial/Commercial DRosidential Water Supply(shared)
Irrigation
FROM TO HATERMU -EMPLACEME—UMFTHOD&ABIOUNT
2 M��ag�
0 . ft. e
Nzalit"'Iroin:Suop"Well:
Recovery
9
�ectlonlell: ft. ft. V
Iquifer Recharge' E3Groundwater Remediation it.
Aquifer Storage and Recovery [3SaIIn1!yBarrIer •-.19-I SAND/C 777-7
FROM I TO -1 MATERIAL M-ETE10D
Aquifer Test OStormwaterDmin'age
Experimontal Technology r3SubsIdence Control ft, fA
Geothermal(Closed Loop)
DTmcer . .......
IGeothermal(Healing(Coolhig Return) 0Other(explain under#21 Remarks) I FROM
a ft.]
CLCA
4.Date Wells)Completed:q* -'l 4 Well IN I ft. zos It- mLt s**q '+e
5a.Well Location: ft. ft. !
Ol k 1 A/OOd 140y"Le-5 ft. ff. C7_3 t=IV
RicilitylOwner Name Facility IDN(117applicablo) ft.
i 762z
25-5/ 7-111-1 IC,V1 rm,&rL_k_&L1,S-e ft., R"I I ft.
Physical Address,dly,and Zip ft. ft. WAA
rAAJ1n;f40G
1,RENARKS
County
Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees;
(if%vcll field,one lotllong is sufficient) 22.Certification:
_N —9 t,5 eZ';?,C r,!) —W zz-
6.Is(are)the well(s)IOPiermanent or.-. Temporary Signature of do—d1fled Well-Contractor
Date
By alping ffifsjinnt,I hereby cerqfy that the Ilvil(s)was(Ivs)-e)constructed in accordance
7.Is this a repair to an existing well: 13Yes or 45No ?A11111 15A NCX 02C.0100 or 15A 1VCAC 02C.0200 Well Consti-nation Staudards and that a
Ifffils Is a repair,Jill oul knouw ivel/consityloilan h0ormation andffiPlain 1/10 Hallfile qf1he copy of this record has been provided to the well owner.
repah-andar 1121 remarks section a),on the back of►thisfonn,
23.Site diagram or additional well details:
8.For Geop.robe/DPT or Closed-Loop Geothei7nal Wells having the some You may use the back of this pagir to provide additional well site details or well
construction,only I OW-1 Is needed. Indicate TOTAL NUMBER of wells construction details. You may also'attach additional pages If necessary.
drilled: 1 BUBMIT TAL INSTRUCTIONS
9.Total well depth below land surface- LOS 24a. For All Wells: Submit this form within 30 days of completion of well.
/;'a)-nudliale wells Iles all dopilks Irdifferent(avample-3@200,and 0) construction to the following:
14.Static water level below top of casing: 60 1 1
ffisvier level is above casing,use 1617 Mall Service Center,Raleigh,NC 27699
(ft.) Division of Water Resources,Information Processing Unit,
4617
11.Borehole diameter. 24b.For Infection M&: In additionI to sending the form to the address in 24a
12.Well construction method: r�o 6V4 above,also submit one copy of this form within 30 days of completion of well
(he.auger,rotary,cable,dIrectpu9b,etc.) V construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR'TWATER SUPPLY WELLS ONLY: 1636 Mail Service CQ'nter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 4,y- 24c.For Water Sunnly&IniectlowWolls: In addition to sending the fokm to
the address(es) above, also submit one copy of tills form within 30 days of
13b.Disinfection typo: �Jur I pie Amount: ._-5 Completion Of well construction to`the county health department of tile county
where constructed.
Formow_i North Carolina Department of Envir oumental Quality-Division of Water Resources Revised 2-22-2016