GW1-2022-00291_Well Construction - GW1_20221222

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well C nitmetor Information:
-V-( 1, n (mot k,ti 14.WATER ZONES
FrtoM ro uescRlPnon
Well Conmmor Name rtL P—
ft. to
NC Well Contractor
/Certification Number I&oErrER CASIInG Mir mumw weasyoR LittBR mr
FROM ft To ft W"ETER in. L TmCKNM Minna
CompenY Name P /
Id.INNE1t CASING OR TUMC
2.Well Construction Permit F. LLj--'ou — D / FROM TO I 11OCKMM I MATERIAL
List all applimble well construction permits 04.WC,CoWy,State.Variance.etc) ft. R v'
3.Well Use(check well use): ft. 2
Water Supply Well: 17.SCREEN
PPy FROM TO DIAMtrtER I SLOTS1ZK I TIRCIMM MATERIAL
Agricultural OM icipa]/Public D FL
Geothermal(Heating/Cooling Supply) esidenlia]Water Supply(single) rt. ft. la
Industrial/Commercial QResidential Water Supply(shared) Ia GROUT
"Irrigation FROM TO 1niT1.ACHA@rr a1R17FODa AMOUfR
Non-Water Supply Well: ft. ft.
jAqui&r'Rcchaxge
nitoring Recovery fL R
tloo Well: O ft, / 0 R.E3Gmundwater Renediation VWl/19.SANDIGRAVEL PACH
uifer Stooge and Recovery ©Salinity Barrier FROM To AIA om.ACEMENr Hanlon
VOL
uifer Test OStormwaterDrainageperimental Technology Subsidence Control ft. ft. 1(�l'' `othermal(Closed loop) Tracer m.Dltf1.[,iNC LOG anr8additioad chaos dRothermal(Heating/Cooling Return) Other lain under#21 Remarks FROM To D64t:RIPIION eer.n 6m�rm,,wv�x m�.ac
ft IL
4.Date Well(s)Completed: //-23-22Weii 111E a' 7P, ft-
fL ft.
Sa.Well Location:
Facility/Oster Neme Fadity ION(if ft. EL R 2 J El
7CN1-/ ��/-i /CGS
I v
Physical Address.city,aod 27Z 70 fL R. —..
L.ROdAR6S t pr' - in:(
county � Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minotes/seconds or decimal degrees: 7 /
(ifwell field,one lat/long is sufficient) 22.Certifications nn
4 ` [�--3 %OCn"/( x 7707%Z. 721�1�/B`fW �A C/ '3�2�/'!1 /l -2-3 Z2
6.ts(are)the well(s)0permanent or QTemporat7 ofCM�ed Well q60fiddr Date
� By signing thls form,I hereby cerify that the wed(s)was(were)constructed in accordance
7.is this a repair to an existing well: []Yes or I_I"" with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known weir construction information and explain the nature of the copy of this record has been provided to the wit osnier.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geopmbe/DPf 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 GW-1 is needed. Indicate TOTAL.NUMBER of wells conshuctnon details. You may also attach additional pages if necessary.
drilled: SUBMITTAL 1NSTRUCfIONS
9.Total well depth below land surface: n (fl) 24a. For Ali Wells: Submit this form within 30 days of completion of well
For multiple welts list all depths if different(example-3@200'ard2®1W) construction to the following:
10.Static water level below fop of casing: (ft.) Division of Water Resources,Information Processing Unit,
If ester level is above rasing,use"!!-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diaarefer. [- yR ( 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rimy.cable,direct po$•a) construction to the following:
Division of Water Resources,Underground Igjection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699.1636
13a.Yceld(gpai) / Method of test: (nre1„ 2OM,, 24c.For Water Sootily& injection Wells: In addition to sending the form to
the address(es) above, also Submit one copy of this form within 30 days of
13b.Disinfection type: AmoonC I'"/ 0 u rU S completion of well construction to the county health department of the county
where constructed.
Fonu G W-1 North Carolina Department of Environmental Quality-Division of Water Resaurces Revised 2-22-2016