GW1-2022-00871_Well Construction - GW1_20220107

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1.Well Contractor Information:' Y l e 3 y20.3
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WellContractorName �— FROM I TO I DFSCRiPt'ItN t r.
Sdn d n
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NC Well Contractor Ccz ficationNumber
v15tOUTER:CASING Mimiilll Wdb OR'LiNER fa"'Qcdbie
FROM TO DIAMETER 1 TIRCFems dL1TERL►L
e t n 7 y ft. In. �,
CompanyName
1&EVER'CASING OR:: DiG:'edfber"mat iWid1l
&by.
2.Well Construction Permit#: FROM TO I MABIE'ao F TffiCIO M I MATERUL
List aft apptkable well construction permits,(Le.-WC County,State Parlance dej n n An.
3.Well Use(check well use): & & tn.
LaIeSupplyWell: :A7.'S=EEN3i ` azFROM TO DIAAWM SLOTSIZE THICENESS MATERIAL
0MunicipalIPublic 0n' n in.
ieating/Ccoling Supply) DResidentiai Water Supply(single) fe nmmercid r3ResidentialWater Supply(shared) PROM TO MA'rERUL: :MELACEIHIIVTME7E[oDBAI1toUNi
Non-Water Supply Well: 0 n 2s--n �.
Monitoring DRecovery
Injection Well: .Z
AquiferRecbarge OGmundwaterRemediation n n
F.19:SAND/GRAVEI:•PACK a"Geab1E}:�:;:':tr>+ h'cS�.'"vie :�:al'<::�:Y'.•�a:_%:: i:.i{;*�:;
Aquifer Storage and Recovery [3Salinity Barrier FROM I I MATERIAL. EMPI ACEM1tENT ME[ROD
AquiferTest 13StomwaterDtainage n ft.
Experimental Technology OSubsidence Control n n
Geothermal(Closed Loop) E)Tracer '.•20.13DRMLINGLOG ditaehaddiddnal'ebeels"ifn'eeeitii iiS: :[c>i:. tz.•tr:,:{.i r.,;:t:
Geothermal eating/CoolingRetunt other(explainunder#21Remarks) FROM To DESCREMONeotoehu .soWmek dae,
C? n d n daar
4.Date Weff(s)Completed: Z•O-2-L Well DN/ fa n
Sa.Well Location: i n z n• p
G/�S p h• z n- ou R• ` I'-;�f�,
a
Fhcility/OwnerName _ Facility ID#Of applicable) n ft.
nll n n MINI ZUZ7--
Physicall�Address.City.and Zip n n
`21:RF111ARI(S�t•i:.,•. :">=i.. ,_ r•1s;.�.r .:^.:
County ParcelIdentificadonNo.(PMdl
rt
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latllong is sufficient
v ) 22.Certification:
d 2-:,14 /�� 11 5,`12 7 7 �1 w c
6.Is(are)the well(s)�ermanent or Temporary Si fCemfied Contractor Data
By sfv tnB this JSrnu L hereby campy Ow the we(k)tuns(were)constructed&accordance
7.h this a repair to an existing Well: []Yes or BNo with ISANCACO2C.0100orISANCACO2C.0200Reh'ComimctionSambdsamtthato
Ifthis is a repalr,JiUautlmown welt construction trlformatton and esplafn the nature ofthe eopyojdrisreeordhasbeenptovidedtothe well miner.
repafrundertill remarkssecdon oron the backojthlsjorm.
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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction detat•Is. You may also attach additional pages if necessary.
drilled•
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (i) 24a.For All Wells: Submit this form within 30 days of completion of well
For mulrlple wells lLrt all depth stfdifferent(esample-3®200'ond2QI00) construction to the f
ollowing:
10.Static water level below to casing: P
p of �� �� (R•) Division of water Resources,Information Processing Unit,
Ijwaterlevd is above eastn&use"+" ets-r 1617 Mali Service Center,Raldph,NC27699-1617
11.Borehole diameter: 9
1 (in) yL I r 24b.For Infection wells: In addition to sending the form to the address in 24a
12.Well construction method:.1-6 T r^�l above,also submit one copy of this form within 30 days of completion of well
(i a auger.rotam eabte.data push,etc.) construction to the following.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) d Method of test: 24e.For Water Suouly&Infection Wells: In addition to sending the form to
the addresses) above, also submit 6IIo'cgpy of this form within 30 days of
13b.Disinfection type: G r ' Amount: S'Q 07— completion of*Well construction to tlie county health department of the county
where constructed
Form GW 1 North Carolina Department ofEavironmental Quality-Division ofWaterItesomees f itnvised2-222016