GW1-2022-09913_Well Construction - GW1_20221031

WELL CONSTRUCTION RE,4 � (GW_1) For Internal Use Only
1.Well.Contractor Information: "
' .14.wATERZONFS.,.. E:':..:7;.• ,.t'.:'.
WenCo�tacsorName FROM TO A DISCLtiplrON
3so f,, oR
ft. R
NC Well Contractor Cettification Number
15..0UTER CASING formuldased wells OR LINSR'rf i" k :: ...: :..
TO Dr.arrlsv THIC(LNYSB MAlERIAI,
Company Name ft & m
w�X 1NNERCASING'
OR TUBINNGG d�ermi121d3ed 1ao c.:= ::A',::•:..
2.well Construction Permit#:_ / 71 9 . FROM To 'r
Lut all oppll-ble well cons-cdon permftr xe.UIG Smt Yuri DIAMETER Tffil M�TEttIAL
CowrO 4 suet etc) tt `R in. `Olt_ P
3.Well Use(check well use): fa ft. in.
Water Supply Well: 7.SCREID�i'; n ;:;.y.r ft.i :_ .:.,<� °y;a•';:e r
FROM TO L DIAMSIER
❑Agncultural ❑Municipa iPublic SLOTS17,6 ;..Tffi SS MATERIAL
Et in
❑Geothermal(Heating/Cooling Supply) 2%esidential Water Supply(single) R ftis
❑Industrial/Commercial ❑Residential Water Supply(shared)
flkni -on
IS'.GRODT;., :-. .'txs_:: •._:. .;..:.
❑Wells>100,000 GPD FROM TO " MATERIAL EMIR"M MODe
eMouNr Non-Water Supply Well: D &
❑Monitoring ❑Recovery
Injection Well:
❑Aqulfin Recharge ❑Groundvtater Remedistion ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROMPID/GR�YELYAC& a" Ere s'sxy':
MATERL►L PRIdCB UMNMTHOD
❑Aquufir Test •❑Stolmwabel•Drainage R
❑Rgerimental Technology ❑Subsidence Control fit ft
❑Geothermal(Closed Loop) ❑Tracer '20 DRILLING LOG atach additiouat sheers it_ -vY. r.
❑Geothermal eating/CoohngRetum ❑Other(explain under#21Remarks FROM TO DESCMPIION
R ete
4.Date Wells)Completed:-D^� -ZZwen IDIF A 75' /19 ft fir
5a.Well Location: tit ft'gjena erl Ce ter' '
Facility/Owner Name Facility M#(ifapplicable) R• fL 1
Lam ft: fir T
Physical Address,Cfty,and Zip R \ ttDs7�t
�l .lL REMAB135; ,
Cry Parcel Identification No.(PIN)
5b.Latitude and longitude in degrftVwinates/seconds or decimal degrees:
(ifwell field,one hu/long is sufficient)
22.Certification:
JI � S .- . N G �
l�f 3D -6.Is(are)the well(s): �rmanent or ❑Temporary Sigoapue ofCertified�VellCoatrachrr /D ;4 ZZ.Dam
7.Is this a repair to an exis' BYES rg Jomt Thereby car*d=the weU(s)was(were)conmuctedb<accordance with
do ReIL' C1Yes or ONo 15ANCAC 02C:0100 or 15ANCAC 01C.0200 iYeU Cgnsltrccrion Srmrdmdt and that a copy
lfthls fs a repair,Jill oni brown wau eoattrr don b+fornwtfon and explabr the naarre o the of thJs record has been
'repair miler#21 rsmorkt section or on the bw*of&storm. f pmvfded to the weU owner.
23.Site diagram or additional well details:
S.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW 1 is needed. Indidte TOTAL NUMBER of wells (add'See Over'm Remarks Box):You may also attach additional pages if necessary.
drilled:
��" 24•SUBMITTAL IlKSTRUCTIONS
9.Total well depth below land surface: 44y tD VQ
For malapk weAs list all depths JfdfJfere a(ermnpk-3(a)200'and 2@100� Submit this GW 1 within 301days of well completion per the following:
10.Static water level below lop of easing: hod ( ) 24a. For All Wells: Original form to Division of Water Resoumrces (DWR),
Ijwater level is above aavfirg pse +- / Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. �`� fir) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(WC)
�//� Program,1636 MSC,Raleigh,!NC 27699-1636
12.Welt construction method: ryGO fit all r`
i
(Lo.auger,rotary,cable,direct push,atc.) 1 24c.For Water Su 1 and O n-Loo Geothermal Return Wells:COPY to the
coutrty eavilormm health deparhnent of the county where install ed
FOR WATER SUPPLY WELLS ONLY:
24d For Water Wells rodncr'n' over 100 000 GPD:Copy0o.DWR,CCPCUA
13a.Yield(gpm)_ Method of test: !r n Permit Program,1 11 MSC,R e' NC 27699-]till
13b.Disinfection type: It ElfAmount: /D Z
- s
Form GW-1 ' �
North Carolina Department ofFnvironmemai Qualify-Division of Water R--I-i- - - -