GW1-2021-06169_Well Construction - GW1_20210901

WW.L CMT`R1JCT'ION RECORD(GW-1) For Intttmal use only.
1.®Veil ContradDr Idormstion: y�
Weil Contrador Name .s PROM TO DESCRIMON
� tt. ft.
el/l/ g C Ag 20 f!. R.
NC Well Contrea a Certificadm Number aer
[I�f Ii4 `T •5 4/" UdQ�•�.>�iy1+� �.,;i'soit To IDf,►s/a•l>sa!1..
Cow NUM
2.well Construction Permit#: �/ { , To uutaiRna t►ut,u
Ltrr aU qPpU-ble well roaffftcNon perNda(l.e.U C,Cowwy,Aafi,varim",arc.) f1. IL is
3.Well Use(week well use): ft � �
wafer Supply Won:
7___
To nlAb�frAs �aTstZ T�ciavcNAgricultural 13MunicipsUPublic ft, IL la.Geothermal(Heating/Cooling Supply) Residential Water Supply(single) M ft fa.
IDdustriaUCommercial Rosidentisl Water Supply(dund)
IL
Nan-Water Supply Well: ft• 1Q-
Recovery ft ft:.
R R
Aquifer Recharge oChoundwater Remediation
Aquifer Storage and Recovery Salinity Barrier mom TO NA GMPLACEMEN'T METHOD
Aquifer Test OStorrawatter Drainage tc: ft<
Experimental Technology [3SubsidCOCe Control L R
Geothermal(Closed Loop) DTracer
Geothermal Other(explain under#21 Remadcs moat TO Ducann m04 eeMr soRlnbe!< stc
& ft.
4.Daft wett(sj Comptrted: Well Too fL ft.
z
§a:°walwLaaatioat i ..: ,.: .r..
. ft ft.
ft t3
Fidly Nino" _ Facility W#(if applicable)
Physics! City, . zip_ fL ft,
A/, 9- 7.3
Carly Paine!W-Wi8cation No.(W _
Sb.Latitude and longitude in degrecs/miauteslsecoade or deelmal degrees: _ )
(if well bald,one lavIlons is suAicied) 2L/Certifteadon:
Al W
6.15(am)the well(s)6ertnameat or [3Tenieorary Sivom of Cad6t8 Well Contractor Dux
By sl nkg t1tlr fora+.I hereby een6 that the wvll(a)war(were)emerwcted to awondawe
7.Is this a repair to an existing well: 13Yes or o w•uk 13A NCAC 02C.0100 or 1 SA NCAC 02C.0200 WeR Coesovct an Swndardr and that a
1f d&it a rgwk fill art known wee!!eonrtrnretion trrfornnation eapldn d w nature of the cc of This--d has been provided to the well owns.
repa6 seeds 1i21 remarb section or on the back of Ak)6m.
23.Site dhZram or additional well dot +elf:
S.For Geapmbe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or weL'
canatructioo,Daly 1 ib'- is needed. Indicate TOTAL NUMBER of wcils construction details. You may also attach additional pages if necessary.
dclUed:
4.Tota1 wall depth below land surface: ���� (�) 24s. Fff Submit this;form within 30 days of completion of well
For mud#p1e wWk We aU dsprhr(f&&rw(example-3(d 200' 100) construction to the following:
10 Statle water level below fop of easing: (R.) Division of waxer
{ r Resoue
Information
Prue U
hr►W t above abe +( axe
atea,Italelgh,NC 276"4617
11 HoerYale ddsasetera , 15171VIai1 Servlee C , ,.... . --
(�') 246.Foti4Ln In addition to sending the form to the xddrese,in 24e.
above,
also submit ozie.copy of this form within 30 days of completion of well
12.well:eonstraetion method:_
COtSrtrUCtloII:to the following::
au�ia;ro6aY.c�k daectpush,.ctc-)'. ,._ k ,
Divislon of Water Resources,Underground Injection Control Prograi
Ft>R WA` R SUPPLY WELLS ONLY: 1636 mall Service Center,Raldg6,1VC.27699-1635. _.
13a.Yield(gam) �E Method of test: 24c.For'VPster bppW A Intectl s Wells: In addition to sending the form to t
13b.Dhlafeetion Am ant. of-
completion of well above, also one copy of this form within 30 days or
type• the county health"depaitment of the county•
where a wuuctod.
Farm OW-1 North Carolina Department of EnveronmMud Quality-Division of Waxy Resoun= Revised 2-22 2016