GW1--03882_Well Construction - GW1_20230609

WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only:
I.Welt Coatis r•IafOrma6oa:
r l!(//t c Cc 7I A.WATER ZONNES
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Well Cow Name ft.3c.yi fNC Well Cow oaN>m>b� tar OR I�IEIt DIAMETER TEMOCgM MATERLiL
% o c
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Company Namc �r ,CASIIrG t)Ii T181NG:
L Well Construction Permit#: / / 0 FROM I TO , DIAMETER TICCICIE55 MATERIAL
List all g7b=ble wall eomvuecortpa=i[5(i.e-Wa Cowzty,State.Yarw=.etc) fr• J ! t°
3.Well Use(cbeck well are): '
Water Supply Well:- I FROM I TO DtAMECER SLOTSM TBICKNESS MATERIAL
Agricultural E]Municipal/Public 0 ft. %
Geothermal(HratiiWCooling Supply) dermal Water Supply(single) / g ;a
IndustrialtCommercial E3Rtsidential Water Supply(shared) .A&GRGUr:
.� FROM TO MATERIAL EMPL CEMENT METHOD&AMOUNT
IrrigatNon-Water Supply Well: fL c>
Monitoring Recovery fL fL
[J.e —
,�on WOL•
Recharge �Crmundwater Remediarion fL
19..SANII/GR&VM PAGii
Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMFL\CEMEMT METHOD
Test. 13Stormwater Drainage ft fLental Technology Subsidence Control fL fLmal(Closed Loop) Tracer . . ..4mal RrbnTi) Odtez(explain under 921 Remarks) FROM TO DFSCRZPITON cobr,trardaess m7ttock ' sme ere
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4.Date Well(s)Completed: o�3 Well LD# D fc S D & �r
5a.Well L,ocatia • fL fL
1 ft f-
yc�
4
Fac�irylOwn�/aName / �/l Faamw II3#(ffapplicable) fL fL
L- r / 1 /G c%� fL fL c
Physical
Gtty,mdZip o fL ft: InfWer.Xian Prvws�-,g Ura
// 2LRtilMARBS £IL)4a
STGn
Co—y Fared ldemifica6on No.(PIN)
5b.Latitude and longitude in degrees/minates(seconds or decimal degrees:
(if well field,0°°lw&cg is sufficient) 27.Certification;
N W r
6.x2m)the wcfl(S)00ermsnent or O Tetuporary Sig a tue of Certified Well Contractor
3y signing this form,I hereby cernfy that rite wells)was(were)constmecied in accordance
7.Is this a repair to an existing well: 13Yes or 90 whit IV.NCAC 02C.0100 cr 15A NCAC 02C.0100 Well Cores�on.Stmdards and dear a
If this is a repair,jiff ara brown we comtr=wn a#orttrauon and apLm he nanrre of dte - copy of diis record has beenprvvided ro the well owner.
r¢psir corder s2l ra rz*semon or on the back of dusforrrt
23.Site diagram or additional well details:
8.For GeoprobdDPT 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-i is needed. Indio TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: S^LJ C ft
( ) 24a. For All R'eIIs: Submit this form within 30 days of completion of well
For mtdb*walls 1W all dep*ifdj#arvu(ermrtple-3@2001 and 2 aC31M construction to the following:
10.Static water level below top of casing: C A) Division of Water Resources,Ifwaterlevel is above�ttse"+^ — Information Processing Unit,
1617 Matt Service Center,Raleigh,NC 27699-1617
IL Borehole diameter. (in-) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
It Well construction method: f c f�r above,also submit one copy of this form within 30 days of completion of Weil
(Le.-we;rotary,able,diteapaah,err) ' Z construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
/ 1636 Matt Service Center,Raleigh,NC 276994636
1-4,Yield(gpm) L Method of test: 24e For Water Supply&Injection Wells: In addition to sending the form to
the addresses) above, also 'submit one copy of this form within 30 days of
13b.Disinfection type 17' Amount:_ e Z completion of well construction to the county health deparmtetn of the county
where constnrcted_
Fattn GW-1 North Carolina Dep—of Envun==tal Quality-Division of Water Resources Revised 2-22-2016