GW1-2022-01947_Well Construction - GW1_20220224

WELL CONSTRUCTION.RECORD ffiW-1) For Internal Use Only:
1.31MeS-tr nftctor Information:
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Well Contractor Natne FROM TO .,DESCREMON
ft. o f 3 M
A ft. D. m
NC Well Contractor Certification Number
retAy Will Pkrnf (0. mom TO DUNIL"MIX TIIIC KNM MATEW"
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Company Now �
2.Well Construction Permit#: U - �3 1�=Q�� FROM TO D TBMCKNMntATsxtAt.
List all appAwbie swell conahwction penWis(l.e.VIC,Count';State,Varfr7llee.etc.) & in.
3.Well Use(check well use): ft. It. to
waterAupply Well: 3 ,
FROM TO DIAMBTFA BLOTSI7E TS(Cffi>FSB MATERIAL
Hernia t(H $Supply) c, tip Supply(side) --ft -- - ii�b
Geothermal Coolie i Residential Water Su
IL
lnduettiaveoITIM«+ciat E)Residential Water supply(shared)
Irrigation J FROM TO I KATFRIAL CEh1ENT •OD&AMRUNT k
NoD-Water Supply Well: d n' 0 %
Monitoring Rt o tt, &
action Well*
Aquifer Recharge 1313roundwater Remedistion ft. tit.
Aquifer Storage and Recovery (3Salinity Barrier FROM TO MATIMIA� x •f w ,Wr METHOD�
WE WNW@ k: :
Aquifer Test 13stomtwater Drainage R•
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tcer ta
(Geothermal tin Return Other LeRlsin under#21 Remarks FROM TO Du ml mON color hafflum sowroe R tymwwn sb%"rye, w.
4.Date Well(s)Completed: - s Well ID# A. ft• rOG
gs.Wen Location: ft• ft.
say A(F- % tr.
--
Facility/Ownef Name Facility III#(if applicable) ft. ft, rN __kv... .
UI W (I r O- oW5 ft. It. FEB 2 4 2022
Physical A[dth-ess,City, d Zip ft. tt.
C- Y Parool Idantifictttion No.(PIIV) r�
5b.Latitude and longitude in degrees/minutes/seconds or declmai degrees:
21.Cerdficadon:
N W
­L in
6.Is(ere)the well(B) Permanent or Temporary Si ofCerdfied Well Contractor Date
By signing this form,I hereby car*that the WON was(Sucre)r,onstructed in awanknee
7.Is this a repair to an existing welt: [3Yes or No with ISA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Weft Construction Standards and that a
O'this is a repair Jill out known well construction it0 mation and explain the nature of the ropy of this record has been provided 0 the wall owner.
repair under#21 remarks section or on the back of this form. 1
23.Site diagram or additional well details:
8.For Geoorobe/DPT or Closed-Loon Geothermal Wens having the same You may use the back of this page to provide additional well site deals or well
conahuction,only 1 GW-1 is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ffnecessary.
drilled:
T SUBMITTAL INtg1 MMONS
9.Total well depth below land surface:
For mul*k wens I&tt all depths O'd(Qereot(example-3@20 0'an 2@a 100 24a. For Ate: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: Z C (ft.) Division of Water Resources,Information Processing Unit,
f water level is above casing,we"+" � 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (tn.) 1
24b.For raga Wells: In addition to sending the form to the address in 24a
12.Well construction method: jiLju.filt1'y abuve,aims subwii utter uupy of iiiia futm wiiain 30,hays of cumpieiiun of weii
(le.anger,rotary,cable,direct p-h,otc.) 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) ,s Method of test: b W 24c.For Water Sunnly&Julec ton 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:„ Amount: 1 b- completion of well construction to the;county health department of the county
where constructed. i !
f
Form OW-1 North Carolina De0artront ofEnvimnmmud Ohmlity.nMaim,of Water Rrxmm•}c o. . .1 11 ..