GW1-2022-00338_Well Construction - GW1_20221222

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WEILL CONSTRUCTION RECORD(GW D For Internal Use Only:—--
1.Wll ATi=C,1(_
Contmeto Information:
C Y ' rz—, ) J\j 14 WATER ZONES i' I _
Well ContractorName FROM TO DESC(2WnON
g 5 7 e 01 €t. 4'0 ft_ m
NC Well ContractorCertificatiouNumber 146 I G
t 'IS.GurEWCASIA16-tm'ail
uitt ased�ve osL1<IYSR IrwLt
Wy�r /iy� I r('_z,/1,,� (�S �W FROM TO DIAMMRZ THiCt(C�NESJS^ MATERIAL
rl CJ I e!/ Irt t(.�� p ft. 7 ft I 1
4 in. e 0 ('K/ G
CampattyNama I&BFNER CASING ORTOB%iYH( thermal closed-Ioo
?..Well Construction Permit#: FROM TO DIAMETER THICHraw MATERIAL
Ust all applicable weft construction permits(i.e-(IIG County.State.Variance.etc.) • ft in.
3.Well Use(check well use); fL ft. 'a•
Water Supply Well: .17.SCREEN
FROM TO DIAMETER SLOTSIZE TBICS.NESS MATERIAL
Agricultural DMunicipal/Public 0 ft- EL in.
Geothermal(HeatinglCooling Supply) residential Water Supply(single) ft. ft
Industrial/Commeroial OResidential Water Supply(shared) I&GROUT
Irti anon - FROM TO MATERIAL EMPLACHMEWM MOD&AMOUNT
Nun-Water Supply Well: ,y - Po"(P 30 I bS
Monitoring Recovery
Injection Well:
ft. ft.
AquilEr'Recharge DGroundwaterRemediation 19.SANDDIGRAVELPACS if llcable
Agnifer Storage and Recovery 0SalinityBarrier FROM I MATERIAL EMPLACEMENTMETHOD
Aquifer Test StomtwaterDrainage ft• f t•
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) E2Tracer 20.DPJ LINGLOG affach additional sheets i€n
Geothermal(Heating(CoolingRebun) Other(explain under621Remain) 1 FROM To DESCREMON(rnlor.hardnessscillmtk dv-etr.
ft. ft.
tvl
4.Date WeH(s)Completed: 4 77 eLvkt-Well ID# ft. M
.v
5a.Well Location:
Yl/1ALl k M Fec,N ft. ft.
2029
Faciiiit^tyl101wnerNamee /V� ,n Famlity]Dff iiffapocable) ft. ft.
1046 CJ LU4967 1 s ltr7flWs b��� ft. ft.
Physical Address,City,and Tap ft. ft.
1A1 p V—r= 21.REMARKS County a Pamet1dovification No.(PR PUr 9-.T.M6(2 TAM v C A,T aF
5h.Latitude and longitude in degrees/minatestseconds or detdmal degrees: AD S NC7
(ifwell field,one lawong is sufficient) 22.Certification:
35, 750 601 N ?8 , 010:2936 9 W i ) - 17-tea
6.Is(are)the well(s) rmanent or OTemporary SignahueofCertifi WeliContractar Date
By signing this form.I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an eidsting well: C)Yes or OFo with 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out bwwn well construction information and explain the nature ofdie copy of this record has been provided to the well ouwter.
repair muder#21 retain-lssection or on the back of thisfann.
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 this page to provide additional well site details or well
construction,only 1 GWA is needed. Indicate TOTAL NUMBER of walls construction details.You may also attach additional pages if necessary_
drilled: Ih SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 d (ft-) 24a.For AR Wells: Subrtiit this form within 30 days of completion of well
Formultiple wells list all depths if dffjerent(example-3Q200'and 2QI00)
construction to the followingl
10.Statiewater level below top of casing: Go - (fo Division of Water Resources,Information Processing Unit,
Ifwater level is above casing.use",(+"t 1617 Mail Service Center,Raleigh,NC 27699-1617
I1.Borehole diameter: �/ (in) 24b.For Iniection Wells: hr:addition to sending the form to the address in 24a
12.Well construction method: d Tl'3'�ZU above,also submit one copy of this form within 30 days of completion of well
(t.e.auger;rotary,cable,directpush,eta) r construction to the following. j
Division of Waterltesotirces,Underground Nection Control Program,
-FOR WATER SUPPLY WELLS ONLY _ 1636 Mao[Service Center,Raleigh'NC 276991636
13a.Yield(gpm) Method of test: P uXVI P 24c.For Water Suo k&Inietdion Well, 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: �� 0' Amount: , 0 Z completion of well construction to the county health department of the county
where constructed.
FomrGW-1 NorthCaroU=DepanmentofEnvimnmentdQaaMy-Divisimo€WaterResources Revised222 2016