GW1-2022-09995_Well Construction - GW1_20221104

WELL CONSTRUCTION RECORD(GW-1) ForinternalUseOnly. RV
1.Well Contractor Information: /,
tzr Cr Y/S C n �/¢ « .14?WATER 7ANPS'>;:i2
Well ContmcturName FROM TO D73CRRr,O
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Lq ✓� R ft
C Well Coaha4lOrCmtifwtfo¢Number i1370UrMCASING fo`r Eulduiiid weyi OR'LINER fa"Bteble gv0eXr4::7.(', ••
II FROM DIMIEfER TH(CIINESS 6fATERW.
camlpW Na ' Q$ M 7 % ft. l. O U C�
16MMUR'(:ASING ORTUBING"`edth'riEMUmed_Ibu ,. z'4'. bJF
2.Well Construction permit#:_PS 7/Cf9 FROM TO DLNIELER THICKNESS 5 -E21AL
Ltrtal(appacab{t wdt enarauetion pesmltr(Le.WC,County.Surm Fadanm et.) it.
3.Weis Use(: eckwell use): fL [t. In.
Water Supply Well:D. '..°i7:SCREFN .•;nb.:+t'ri.:!:<>i.P::.tT4"?.SRh.�iit{:�n`.'s7.Sk'�-;fb'e:.^e;,:BY,"rit^J3S
FROM 117AB E R MZE THICIWFSS MA76RW.
AgricWlural �MwicipaVPublic - �_. O R R to -
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. R
. Indushial/Commemlal EiR29idential Water Supply(shared) rIWGROUYibhI10G[: IML:.at._l.':x:;,:�tisl:l,t"
—iltrittation FROM TO afA7ENAI. FSfPf.ACEatEtrf MErBODaAMOUNr
Non-Water Supply Well: a D.
Monitoring [Recovery fL ft
Iq(ecgim Well:
A uiferRectra e R R
9 B �Graundwa[er Remc)iatian
A infer Storage 7r7
•.ble*.'[fn'rKx.::rfliti:r.5.` 'tiiY+."a"itr5ftibsdL;.i?";
q rage and Recovery Salinity Barrier ATERIAL F.Me1.AC=.rmEnioD
_ Aquifer Tess r3StormwaterDrainage
Exper"Dnen Technology Subsidence Control
Geothermal(Closed Loop) Tracer
Geothermal eatin Cooling Re Other(eaplain under#21 Remarks) FROM To nFscnsnon radar umdaa,.,aarta<a em
U R I A 0 ft o
4.Date Well(s)Completed:15S- g-ZZ Well ID# G fL R .�
So.Well Location: )y R 7 R
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PhyBealAd&ess,Cft1,aad2fp �o9 t1f y R It U .
N•! � - ki S211REKARK93>':. Y.':.::41Fi:L.Stti• ? r #.. 3 :..,f t=C1
County - Xsucet rdentiSeadonNo.(Ptt�
Sb.Latitude and longitude In degreestatinutes/seconds or decimal degrees:
(ifw.0 field ave Wines Is auIfick.t) 22.CertiBcationt
,%_ 0J7t.34. 1;-7 ' � t5993j' w _ 51 Sr zz
6.15(are)thewell(s) ramneot or OTempormy byeran,a C Well Contractor Date
By rigning thb form.I hereby"no that the wea(s)tuns(rvue)easmucted in accordance
ZIsthisarepeirionnextvtingweU: [3Yes or [DNo^ wlth ISANGCO2C.0f00ar ISANCACI2C.0200{Fall Comtrualan SraM ondlhwa
IfauIs a repaaly,fill out Mown well eonarructlon information and e+ptafn the nature ofthe cof0'ofthls record has been pro vldrdto the relfmvner
repa4 under Y21 remark recdon or on the baekofthisfarm.
23.Site diagram or additional well details:
8.For Geoprobt/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only GW-1 is needed- Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifaecessary.
drilled:
r-� SUBMITTALINSTRUCTIONS
9.Total wellldepUr below land surtace:_,_ �"y (ft-) 24a.For All Wells: Submit this firm within 30 days of completion of wail
Fo nruluple weffsletalldepth,{/'d/fferent(esam7-3(200•and 2@100) construction to thefollowing:
10.Static water level below top of easing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwaterlerel b abava caring we//+� 1617 Mail Service Center,Rnleigli,NC27699-1617
11.Borehole diameter: fo (in.) 24b.Far Injection Wells: In addition to sending the form to the address in 24a
12.Well eonstrucdoa method:_ 6�/rr`1 above,also submit one copy of this form within 30 days of completion of well
12.Wel,ronsticable,.metpush,etc) J construction to the following:
i Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY ONLY: 1636 Mall Service Center,Raleigh,NC 276994636
13a.Yield(gpm) � b Method of test: 24c.For Water Supply&Infection Wells: In addition to sending the form to
ff22 the address(es) above, also submit one'copy of this form within 30 days of
136.DIsia(e fioa lype: �/iRY Amount: J O z , completion of'well construction to the county health department of the county
where consuucted.
Farm GW-I North Carolina Departmento(Envimmeental Quality-Divhton of Water Reso=m Rev¢cd 2-22-2016