GW1-2022-10617_Well Construction - GW1_20221122

WELL CONSTRUMON RECORD(GW=1) For Internal Use Only: -
1.lyfil ContractbkInformation:
Lt", �r! 14.WATERZO]ES.
Well Contractor Name FROM TO I DESCRWnON
G�
NC Well ConttactorCertificationNvmber IS.OIITEEtCasml+GTmrumto<vE oH>EICQER wnte7
FROM TO DUN ETEM THICKNESS MATERIAL
V VV l l(✓ ft. ft. in. G
Compaa ny Naameme I6.dL MC GOR O{ thertnaIc[ased-Ioo
2.Well Construction Permit#: FROM TO I DUNIEKER I TMC[fNsSS MATERIAL
List aft applicable well construction permits(i.e-UIC,County.State,lrariance,etc.) ft. it.
in
3.Well Use(checkwell use): &
JA
ater Supply Well: 17.SCRFM _
FROM To DIAMETER SLOTSIE6 THICKNESS MATERIAL
giicultulalMunicipa]/Public 0B. tn.
eothermal(Heating/Cooling Supply) residential Water Supply(single)n ustrial/Commeroial Residential Water Supply(shared) GRODT
rri ation - FROM I To MATERIAL MPLACE E6IENT OD&AMOr)HIr
NDn--Water Supply Well: ft y' ft• o!+ ti' /X046.2
:7.3Monftring ecovery fL ft.
Ddection Well:
ft. ft.
Aquifer'Reaharge 00roundwaterRemediatioa
Aquifer Storage and Recovery FISalinityBarrier FROM To -_- MATERMLe MVMLACann NTnMMOD
Aquifer Test E3StormwaterDrainage ft. ft
Experimental Technology E)Subsidence Control ft- ?+ .• ' ?
Geothermal(Closed Loop) DTracer 20.D LOG(attach additional sheets ifn
!_!Geothermal(HeatingFCoolingReturn) Other(explain under'21Remarks) FROM ft ft.To DESCRRMONtrnln.tm*=-.sonlmck abr-ate
4.Date Well(s)Completed:1l�f / `Well ID
ft• ft. NOV2 2 2022
Faoility/0 erN�aAme/ L /� /FyacilittyI[V(iiffapocable) ft• ft' i %
/ V �/°' : nal L_ `��. (-.41fJeA ft. ft. 161;v;c,e t ,
r.9 '7iu0U ..
Physical Address,City,and Zap ft ft.
2I.REbIARSS .
County PamelIdenlificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds ordednMI degrees:
(ifwell field,'one latllon g is sufficient) 22.Certification:
6.Is(are)the well(s)of rmanent or oTemporMT Signature of Certified Well Contactor Date
By signing this form,I hereby cerify that the rveff(s)was(were)constructed in accordance
7.Is this a repair to an existing well: . I. or ON. with ISANCAC 02C.0100 or I5ANCAC 02C.0200 Well Cons"dion Standards and that a
If rbis is a repair,fill out known well cons tructlon.information and explain the nature of the copy of this record has been provided to thervell otvtter.
repair totder#21 remarks section or on the back of thisfortn. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same , ' You may use the back-of"page to provide additional well site detail.:or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells; construction details.You may also attach additional pages if necessary.
drilled: n SUBA=ALINS RIICTtONS
9.Total well depth below land surface: of yZ UP 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diffbvent(example-3Qa 200'and 2@1005 Construction to the following
10.Static water level below top of casing: 2 (ft.) Divislun of Water,Resources,Information Processing Unit,
V' ater level it above casing,use'+ff" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 24b.For Iaiection Wells: In addition to sending the farm to the address in 24a
Y�Q)�r + above,also submit one copy of this form within 30 days of completion of well
12.Well oonstraction method:
(i.e-auge,tut".cable,dkee tp ush,etc.) construction to the following:
Division of Water Resonre es,UndergroundInpecdon Control Program,
-FOR WATER SUPPLY WELLS ONLY: _ 1636 MO Service Center,Raleigh,NC 276991636
13a.Yield(gpm) Methad of test: OIAA6,0 24c.For Water&R&&Inieetion Wells: In addition to sending the form to
L I the addrass(es) above; also!submit one copy of this form within 30 days of
13b.Disinfection type: T t'I Amount: completion of well conslructton to the county health department of the county
where constructed.
FOM GW-1 North CamlinaDepanmentofEnvimnmentolQuality-DivisionofWaterResonrccs Revised2-22 2016