GW1-2022-10650_Well Construction - GW1_20221128

WELL CONSTRUCTION RECORD(GW- Forinterna[Use'Only:
1.Nell Contractor Information: 6
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Roll To DFSt:IU OIN
1Vell ContraclorName 6 It. R• -p 11 cl�J
Ne wen Conwetoren ificationNumber yr OV=CAS><NG(thrmutd wells)ORLMMara ).
!?RO]i TO DIAI WIM THICOFEW' HATERIAL
e1,V;('eS ft.
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CompaayNante _ 16.II0MRCAMGORTOSINGf closed-low)
2.Welt COnstrutdion Pe l ti O 4 Y MIUM 170. '. .DMA%,M THICItNM FERTERAL
at all applicable well consttucdonpetmits(i e.UMCamay.State.Variance,etc.) O 'c i ro� A,
3.well Use(check well use):
Water SupplyWeM M. 17.st� ! '
�'R FROM TO DIANn3TER SLOTSIM TMCKNM Al"EMAL
Agricultural E2M, vipdTablic rr ft.
Geothermal(Heating/Cooling Supply) csideniial lYatcr Supply(siuglc) tt. ft_
IndustiiallCommixciat` DResidential Water Supply(shared) i�GROUT
— - 11T) Etion FRO St TO MATERIAL EMPLACOMN751 rIIOD&AM011 PP
-- - Non-Water Supply Well: tt. tt. t7�r ,Fk - Z iC.-- -
Monitoring Recovery R. fE-
",
1wection Well: tt
Aquifer Recharge 0Ground�vaterRcmediation 19.SANNGIRAMMEMr.� licabtr
Aquifer Storage and Recovery E3SaIInityBarrier FROM To arm3rtrvrer. EMMALEy,�T71fEMOD
PAC
AquiferZ st 03tormwalerDrainage IL it.
Everimenta�l Technology [)Subsidence Control o• R•.
Geothermal(Closed Loop) OTrdccr 26.DRIMIMGLOG aithtehaddttlonolahoetsif
1- cmd,crind(Heatin !coolie Rctuin) {?tiler ex air under#21 Remarks) FRo�i ' Tu f►EscltteTtoat(aacr;tom sourmctt sip-ar:1
D it. � tt., LotC'
4.Date W0H(s)Completed: - 18 ZL. Well M# °ll� R' sC R• r/)tYc7 y f�
go.Well Locations . ,.
M a: l t�-_r� fc. eI b V
racifity/Oaaer Noma Fh6liity IDS(Napplicable)
-Sol WMA_(�I ra i:4" br-. {CaL, i NG n ft.
Physical Addrew,City,audtip ft' iGPFt?4Ltr,1 Ar.eau' i"�.Lrta
MC Du t'e'l l 17 a, vb 3�.1�� Z1• - .
County PamlIdeatiGtxtianha.(P11 !
Sb.Latitude and longitude in degreWminatesfseconds or detdmal degrees:
of well field,one larllong is sufficient) 2L Certification:
- 3Sb Lt3, y953�3S1��tH 816 s'}a ►3.9332 '�j ! W
US(are)the well( airwmanent or Tempo;Noll
,, 4igoamroafcertmedWell Contractor Date
By signing tf&form,!hereby cerdfy that the aeN(s)iros(here)co ianxied in accordance
7.Is this a repair to an existing welt: Dyes or vrilh M NCAC 02C.0100 or MNCAC 02C.0200 tVell Construction Standards and chat a
lfdas is a repair,fill out lazown hell construction informutlaq and eiplauh the nature ofthe copy of this record has been prmided m the well ottmer.
repairunder221 remarksseation oronthe bad,ofthkfann.' 23.Site diageam or additionAtwelt details:
$.Tor GeoprobelDPT 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 1 ow-1 is needed. wicat�c ToFrALAttImwt of wens consaitetion detais.You may nlso—EA%a"tionalpngeo ifaoeescary.
drilled: cilia aT ids_ftttcrriiit+ts
9.Total well depth below land surface: 5 0 (D) 242.For All Wells: Submit this form within 30 days of completion of well
For mumpte urells list oll depdcs tf d Fffewd(example-3 a200'and 2@I00) construction to the following:
10.Static water level below top of casing: (0 CD Division of Water Resources,Information Processing Unit,
Ifirater lewlisabore casing,use"+" 1617 Mail Serf ice Center,Raleigh,NC 27699-1617
it.Borehole diameter: • Z (in.) 24b.For bdection Wells: In addition to sending the form to the address in 24a
A above,also submit one copy"of this form within 30 days of completion of well
12.Wen construction method: eonstntetion to the following!
(ic.auger.mmry,cable.dh=push,ctc.) U�—••••••�—•
Division of Water Resources,Underground Iudection Control Program,
TOR WATER SUPPLY WELLS ONLY; 1636 Mall S"c'e Center,Raleigb,NC 278916M
. �
13a.Yield(gpm) � 1vlethod of test:\aJ C6I'l"1e2 24c.For WW SpgQIy&Iniectlon Wells: to addition to sending the form to
the address(es) above,also submit one copy of this fort within 39 days of
f3b.Disinfeetion type: (�� l e r� - Amount: 5 s completion of well construction to the county health department of the county
where constructed.

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