GW1-2022-09956_Well Construction - GW1_20221104

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WELL CONSTRu=oN RECORD(GW 1) • ForIntemat use.Uniy: r
1.Well Contractor,Information: _ -
V,. u O B1 14<1/t :14:+WATER �.;L," .,, }
ZOPIf;S. �.33•ka.�vz:4::�}:tii 's.
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II � t` �• r J .� GNCWd1ContrattorCet fica6t iM mbar ySING foFells ORZIIHER fa"'lIa'7rTe fit;++7a✓,..,rrn; -,
DT IMUR TMCKNESS FVu►aERrar,
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Company ame
0� °16.'II'IIdERCAS ORritlBlPiG' ilieen7elelo`fed=lou?3YG?,d. ?i;;s�arSY'u�`d,'.m
2:Well nstinctionPermit#: 1,J-3 1 FROai Tol DlatttEMP. Tmcra�Fss ttr�Tsautz
ZrstaRop!/eable twell constnretlonpennlcs(Le.UIC.Cotmty.mote,Vadanee;urn it ft I in.
3.Well Ilse(rheckwell use - fL
WaterSupplyVelt: �17:SGREEWAN �G�t'dk{i iil'k£<;k"ass'&'.'yzt�9ti.R'ss7:5?s;�7i.Iiti>re 'S,">�ffir�3
FRO51 TO DIAalTsTER SWUM TEIICIn�tE4S MA7BRiAL
. Agdcultuxal 13MunicipAY26blic O it ft id
Geothermal(Adating/CoormOupply) j3Res1denfid WaterSupply(single) ft !t
lndustrMCommercial Residential Water Supply(sham_
IGbo
FROM TO REATEersupplywell: ' !t it:ring ORecovety'•Well: [/ r . ,64 .t
0GroundwaterRemediationa""'-IIcabTe r�rJ,Pt`�'2:t* 14tStolageandRecOVery13$alwayBarder FROM• TO. tNATERLIL EMeLATest OStomwaterDrainage mftentalTechnology 13SubsidenceControl !t: fttmat(ClOsedLoop), �Trae:er ?1U:DRIGLINGLOG dtfaehadditidn`slbfieet3i[ ►++t�?SLkil?�',t�.e},4nrji^>5 �,�mal(Heating/CoolingRetum) Other( i iander#2l Remarks) FROM To DESCRa''rtoH(eotor.6mdoe+r soetmeTc eia,ek,
. .
fl: ft
4.Date We (s)Gompleted: ./6-.Z5'-?.Z-WeU D# fa b ft:
5a.WellLecaffone 7,0 R O R ,Gc� •
C
PS etft. .$ 0 I
Fdedlity/ nerName _ Faaft WN Ofapplleable) 6 it: ft. -
�.�Pw«`rt tc���i�,,�� l7 c 98f '� L ��n
bysicat dews.City.nndX{ . _ . ft ft.
}`Ja` i+ iitfiiSu�
County .FamelIdentificattonNo.(PDO „
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: N O U 41
(ifwell field.one ladlong is sumdent)
� 22.Certiticatioa:
.J 31: 96 VT Nd. S�L / � � �y.l`'�t
6:Is(are)ttieweli(s) r Muint or 13Temporary sr ofCech a1yVeUCoatractoe gee
By s/gnhrg rhea jom4 I hcAW eerto lha{the weU(s)twos(were)ecnsraueted to aeeprdame'
7.IsthP;arepa1rtoanexEgftgweII: E3Yess •or OW twlrhldifNCtCO2C.0100orISflNQiiCO2C.0200R'elfComtruel{onSrairdardsondrhata
Ijthlsfs�arepa/rfi/IoutknotvntvelleonstracttonbjonnotiortaadeplaMfhenatareojfhe �PY� R !d�sBaenFtow/didtotbetvelldwtw' '
repatrurtder#2l remarksseedon eron&ebackojth[sjorm. i.
23.SIte diagram or,a4ditional well details:
8.FokR,Geeoprobe/DPT or Closed-Loop Geothermal Wells having the same. You may uses the bai:Tc of this page to provide additional wall site detat'ls or well
c�trilfod,only IGW-lisnecde:d.IndicateTOTALNUMBERofwelis constmctiondeWIL YoumayalsoattachadtfitioaalpagesNnccessary.
• SUBMITTAL INSTTtIICTTOI+TS r
9.Total well depth beb►wland surfacer 4767 (ft:) 24a.For All Wells: Subatt't'this form within So days of compla&'of well
For mahOr awe/IsHsialldepths{jdWarml(rxampf'r,3(a)200•ohdT©100) ,
coostr uction to the following:
10.Staffemater level below top ofcasing: c7 @ (ft) DIviSloaofwatecRes ces,InfonmtationPracessiagUnit,
Ijwaterleweltsaboveearla&rase M7 Man senitie cent&,RaleiA,NCZ7699-1617
11.Bokehole diameter: (itt.) 24b.For'Iniection Wells: In f ddition to sending the form to tiie address in 24n,
ab _
ove,also sulmait•one,copy of Pa form,within 30 days of comph6n of well
12.WeII tons trued oamethod:_
iyeabt.d¢cpusbelm)(ie.augai coastrutiontotiaSoUowng:
FOR ATERSUPPLYWLLSONLY: i
DlvisioaofWaterRe;oyrces;UudergrouadInitectiba'ControlProgram,
_�, 1636MMIRServlce Center,Raleigh,KC2709-1636
s91�d�1?m) � _Method oftest: .�f 24c.For Water Suoniv&Ittfei6nn Wells: In addition to setuling the form to
the sddtxssW) about, also sub ilt one*copy of this form within 30 days of
13b.D�Jnfectiontype:z1,&i^.H-e, Amount:_ "r e 2 , completion of'weU construction Ito the county healtit 21epa►trnent of then county
whereconstructed:
ram GW-1 1TouhCamlinaDepattmentofEnvimamraafalQualttyDIvisronofWaterResouwcs Revisedift-2016