GW1-2022-10217_Well Construction - GW1_20221111

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
ILWAMMMIS
.� 6. ROM TO DESO OIN
1Vel l Contractor Hume d � J� � i 1 I O�
q V�^� '
NC Well ContractorCeeti6cationNam6er ,� �- �+,ts131zS[t g�O{tbrtaaVl treIIs ORI (1f
11^'C- EROIf It1AMMM MCSNESs DSAT6RiAL
1' ft. R. in.
CarnpsnyName 26.IIVNMCAMGORTMING{eotT�ratalclased•] )
2.Weil Construetion Pernnt 9: �2 2 n 1 2S— 9RDIM I M nMMM arnT
Lut all appficable►ill constniction permits(i e.IIIC.Cawy.Mate,Varlanoe,etc.) 0 R' tt• 2-r
3.Well Use(check well use): ft-J.
Water Supply Well: 17,11CREM
FROM. TO D M&TSM TS[CKNM IATERiAL
Agricultural UZdantial
'''PaMblic ft. II. In.
f3cathcrlttal(Iicating/Cooling Supply) Water Supply(single) M ft-
Industritlycommemial DResidetltial Water Supply(shared) IL GROUT
goon FRO51 TO AUTERtAL E}tPLAt f&\T oD&AAtouNf
Nan-waterstupply Well: D II. tt. � l
Monitoring DRecovery II, JC % -_
bliection Well:
R II.
JAquiferTest
quifer Recharge �Grovndwafer RemediationquiforStorage and Recovery Salinity Barrier 34SAND1tiEARSrrPA 'PltO]fTf! ALA�HIALNTh1ErHOD Siotmwaterl)rainage n• II•xperimental Technology DSubsideneeCoMml (L It.eothermal(Closed Loop) Tracer 24 DRUMGLOU(attu haddhianelcotharind(Hato ICooli Rottlm) Other( lain under#21
Remarks) �eosl � nFst RleTtaN:ntm: snlumrk ,da.ea�)
t:. 5 tt. 11t
4.Date.Well(s)Completed: Well ID# S3 II• G R•
Sa.Well Locatioat II•
Pncllfty/EhvnerName FnuTitp lDG(ifapplicabte) ft. fL NOV 1
-Nil 8 cAlo Shoals Ot La h j tc n: ft.
PhysiedAddress,City.andZip o7S��(o & R. DVVQ1uCCa
ED s3
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrealminuteslseconds or decimal degrees:
Dwell held,one latllong is sufficieta)
22,Certifientloa:
.35 6 39 ' SZ,1 69►1 Il 11 -32.69
Us(are)the well(s) (Manent or E)Tempnrmy ante o€CeRified Well Comractor Date
By signing Urfs form,f hereby rrrr jy that the MUM uns prere)co mruried in accordanee
T.Is this a repair to an existing well: Yes or O tvfat 15 NCAC 02C.41a11 or 15A NCAC 02C.0200 Nell CatutnecSvn Standards and that a
b('t/dr f:a repair.Jilt our hnou.t.veil emrstroetion it formntton and explain dre nutare o.rdw CUM ofthir record has been ptm4ded to the well arner.
repairander02l remarbswtionoronihe&d-ofthisjonn. 23.Sitottlfagra@Oraddilioa0lweildetalls:
8_Sor GQogrobe/DPT or CloseB.E cop Cenikerou l Wane Moving the aomc Yen may use the back of this psge to provide additional weir it.details yr won
construction,only I GW-1 is aoedcd, lndiaam TOTALNUbIBM orwelus construction detals. You may nl lso attach additional pngoe ienneesaory.
drifted:
9.Total well depth below landsarf'ace: i lD AA 24g•For All Wells Submit this form within 30 days of completion.of well
Farmuhiple icells lht art dep&ijdffoent terample-3@200'and2@a 100) Construction to the following:
10.Static water level below flop of casing: V M) Division of Water Resotlrres Information Processing Unit,
If crater le►rtis above casing,use"+°
r 1617 Mail Service Center.Raleigh,NC 27699.1617
U.Borehole diameter: (P• 2- (i`n,..)�1 24b.Ear rnieetion Wei In addition to sending file form to the address in 24a
17-WeR construction method• �r - above.also submit Out Copy of this form within 30 days of completion of well
(t.e.auger,mrary,cabic,dir=pag4 cic3 COIlS[NCIion to the INOMBE
Division of Wader Resources, ildergrmurd Injection Control Program,
FOR WATER SUPPLY WELIS ONLY: 1636 Mall SWVice C0Rl)M RMe0,NC 276991636
13a.Yield 0m)s _• Method of tom 24c.For%hr &I l�tiM W l e• In addition to sending the form to
the address(es) above,also subunit one alpy of this form within 30 days of
13b.Disinfection type:C I0"YC Amomb Ctlmplefion of well entrsttuction to sbe.County health department of the county
where constructed.