GW1-2022-09984_Well Construction - GW1_20221104

WELL CONSTRUCTION RECORD MY-1 For Tntemal Use Only:,
1.Well Coata}aetorInformation: _ '
�j �. , 1. . . . I -J
Ci/` / :14:+WATERZONES`,,:�";'wa c:,ar::tfi:•.-?ir`�l 4; '!.':? R'ni=tr.',`.'s: i s t t:;;�:35?
FROM
701
DESCRIMCR J
Wencontrac Name
I tt ft
NC ellCoatmctarCettificattonNumber S:O1TrERQAS G foi tntdfl ea�ed:well+ ORZiLVER fe"fimbie','.,►'r:x,;�:i'..'�fi
�� f -/1 J�3`i)S , 17C i• FROM TO DIAaffirER" TIUCMESS I iNATERiAL
ay .16:•II�OMCAMIGOPUMBING''etthEiwalelWid=hod :YVNPe' .sY e.a ,
2.Well Construction Permits. �t�t f J d C'7 Morel - TO DIAb>ETER TMCKNESS ' ntATRUAL
tlstall app&gbk ivdl tonstmedonRetmits(Le. G CotntW.Stag Variance.eta) ft. !n'
3.Well Use I(checkwell use): ft' tt, p in.
t�17• "�a+'5'.:�`.n''•}.'it+�•�'eiY.13�:1:5Y.'ikZ'rtii:':7�7Y•lA"&VT l�.''�.at-'"1ii t.;ke'Ff:t:CtC.'n•:t'���'rdSS?�}
WaterSupp Well: FROM TO I.BLawrot SLOTSUE TIUCHNESS MATERIAL,
Agricultuial. [3MunicipaUPublic O fc
Geothermal(Aeating/Cooling Supply) �esidenfid Water Supply(single) f ft in.l
htdttstriall ommercial oResldeatiatWater$upply(shared) A&rGROUVv-)1MA' a�;��Jzs:v <".:'v:xr4 e" i �! yea. 'SG' i is�,i;,7;Ha
t10n I FROM TO MATERIAL' EWLACEMMMMEMOD&AMOUNT
Non-Water Supply WeII: ft' it' a, v '
,,
. Monitoring Recovery
Igfection vi�ell: m �
A uiferk�chaige DMoundwaterRemediation F>9.
q :SANDiGiRA •PACK:ita '1•im61E :£z?3E :.?,tY,•i..5f! M- ..k s43f ors?i
Aquifer Storage and Recovery [311elini Barer FROM• To IMATERU►L EMI ACEME BIMOD
AquiferTest E3StormwaWDrainage tt I'
BWftentalTeelmOlogy OSubsidenceCoatcol
Geotlielinal(ClosedLooP). [3Tiacer ' 120130JIMOLOG a&aaiiaa ttit- btkeis°It __ss' ':�e:4:s; .ti:°,"li 'gar:
_ Geothermal.(Iieating/CoolingRebm) Othei(emwmunderaiRemadcs 'FROM To nE5 oNwmreasda toWmek etas
.
4.Date Wells)Completed: jG:2 ]DO - ilw tt, OV7 , .
S.a.Wenllcai�tion: 0010 V n
,I�/r°rr�t t � iJ°� :�d_,L ' • �- tt 'tt ` ..�;��. , ,iaw.�,a.�� `tLa'R>z
Fbctl[tylOwgerName _ .Faaft ID#(it applteabk) ft. iG
Z /A I _<Cdrg��fs 4, aAr/trr7)7�N.f/. G
ST.dAd&=%C1W.endVP qq `►' (��7g tt R. IrliGivi?cs d:�fl ter G'^a��.c ,
��T � �ir`�/` b21. YiJi.^.1$:s.r_a.��i+.s.c .alts(Wu:sL�•i i�i..4'•�'•.y:.9$' a—'a;+r'.''�"b�
Ceun' ty Yaredblem35catianNo.(F"
5b.Latitude and longitude hi de gi green/minutes/seconds Or decimal degrees: ,
(ifwellfidl one lamong is suffii rent)' 22.Certification:
" 736�`: y
6.WIN)LW- mn 61l(s) er neat or Tempora Si Welt Dace
h
. I ry
By sigaing,thls form I hgMby eatt{fY7hptthe sveU(s)teas(Whq?constructed in'accordance
%U this a repairto nn existing walk OYes or QNo with itiNCACO2C.0f00 or isAivcAc 02C.020o hell cvn haci an Standandtandihat a
Jfthislta repair,fill ouftmotm ivell construction blformaRonand prpiain thenaaaeojthe eopyofihl rnmdhwficenpmvfdedto'fhamelimmer. '
1'
mpatrundcr#21 itmarlasccttdn oronthebarlcof&bjotat:
23.Site diagram or additional well detRiisd
L For 14probaMPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or wall
construction.only I OW-1 is needed.IndicateTOTALNUDA BER Ofwelis• constntctioa details.Yonmay also,8ttacit additional pages if necessary..
dn7led: SUBMITT INSTRUCTIONS;
�1 I
9.Total well depth below land surface:. • "7�2 5 . (fn) 24a.For All Wells:' Submit this farm within 30,days of consolation of well
FormuUiplevdlsilrt all depthslfdrema(examples @200'and2@100) coustructiontothefollowing: 1'
30.Statiewaterlevelbelb*top;ofcasing. (R•) Division of WatorResources,Info=mationYrocesstngUnit,
Ifivaterievf isabowcas►n&usa+' ;1617Mai1Service6iter,Raieipb,NC276991617
11.Bortole diameter: //// I
I �If[ (in.) 24b.For Infection Walla:,in addition to sending the form to the address in 24a
above;also submit one.copy;of this roan within$0'days of completion of well
12.Well construction method:_ r CJ l�' 1l construction to the followiagc
(ie.auger'.iotazY.eablGdieeetpusl4eta.) ' � � '. .
Division of WaterResources,Underground Injection Controlkrggrapy
FOR W TER SUPPLY WELLS ONLY: 1636 Mail Service Cinter,Raleigh,NC 27699=1636
13a.Yield(gpm) Method of test: ','f •re. 24t:.For Water'Suaoly&iniection Wells In addition to sending the form to
t the address(es)above, also sub, one'c6py of this form within 30 days.of
13b.Din fectioatype: t Amount: ' compkdoa ofwell constmedonIto{the county health depattmgnt of the county
wherecoashucted. p !
Founow--i NorthCamlinaDepadmeniofEuvkomncntalQuaUty-DIvfsio¢ofWaterites es Reylsed?r22-2016