GW1-2022-03717_Well Construction - GW1_20220330

1.Well Contractor In y•�
nfformation: I I
" sO !7 K�l�'hel✓�J/ '14:�wnTlltzoNEs°,s=
WeUConhaettirName FROM TO DESCRIPTICH
c1 fa tt. a I
NC Weil Contractor Certification Number S19;OUTER:CASIIVG foimniti " ive119 OR'IdNER s"Uceble:i!;:r:s ,•„ ::�:
FROM TO DIAMETER i TLUCIINESS I 5114TER1AL
it. .2 fe 10.13 25-, 1 f' V C_
CompanyName
�;.16.'II`II�ER'CASII�IGOR.TUBIIKG: eutiid►matilmi:d�too' Mrs:;<<z:::?i=:,�'�:?.re:dx';:i;
2.Well Construction Permits: u 6,5'0 CI FROM TO I MAb> M I TMCMESS= DIATERIAL
Ltst all appffeable wdl construction permits(Le.WC County,Stam Parlance,etej
3.Well Use(check wen use): &, tt, to
Water Supply Well: :�17.'SCREEN.�.:r�,:,�:u;'"1:'•�,(n•!!::1'i':aiii1J's�"3.u.'i:-i,4'.'y?:'•� �4'r•;i,;ii.:�:� r�;'",3ti'.•i�;.�Ji
FROM TO I DIAMETER I SLOTSIZB I TIHCMMS , atATERCAL
Agricultural j3MunicipaUPublic O ft: tt in.
_ Geothermal(Heating/Cooling Supply) 0e`dential Water Supply(single) R
iffdustriaUCommercial ORwIdential Water Supply(shared) -•. ;:< :, r,
Yltt:GROnTI.4S':�'f:.`.••i,•::::•i:r.!•.:��C.:r.+':ii:: _ !3:':it'':n?: i�'ii'vS•:�3's``•:a{:s'�' ti=.frs'%a=::i?:1
Irditation FROM TO I MATEPML'• EMI AM ENPMEMOD&AMOUNr
Non-Water Supply Welt: O 'LIL
¢,, +.' e r!f�:7i %tS•�
. Monitoring ORecovery R te,
Injection Well:
AquiferRecharge 043roundwaterRemediation
AquiferStorageand]tecovery �SaliniryBarrieC A9 SANDiGRAV=PACK a fi�ible?•',•::r.'.?n%;;a�e4E
FROM TO DIATERTAL EMPLACOUMVIMOD
AquiferTest OStormwaterDrainage R ft.
Experimental Technology OSubsildence Control . ft: ft.
Geothermal(Closed Loop) 13Tracer `:20193RiLLiNGLOG 8tt8CllIIddltlOGatlhati fIIGG!!Sa' li�S +:..`•�%s?c:r;?r'.,-,.
FROM TO DESC RUMON color bmdaemsaahoek sbe,eta
Geothermal(Iieating/tooling Return) Other( lain under#21 Remarks) O. R g R
4.Date Wells)Completed: '2 Z WeIIID# ft. 4 y ,4h
Sa.Well Location: fw Soo R'
_ '7' ►n in,,.r ray n ft.
neWownerName _ FaeftIDS(tfapplieable) ft. ft.
�2.27.5-7 S-' �2-0s&44 4nl'ey J7 ct ft. n.
P6ysicatAddtess.City.aadzip y ft, tt.
L/y / 121.REi1fARlts•>. .u.;.t
County .Parcc1MentWcat1onN9.(P"
Sb.Latitude and longitude in degrees/miantes/seconds or decimal degrees:
(ifwen field,one lat/long is sufficient) 22.Certification:
c
I.
6.Ia(are)the well(s)OP-ermaneut or 13Temporary Sir-a*cofCcffiffcdWcHCoutract= Date
By srgaing this form,I hereby eve that the ivell(s)nos(were)consoueted in accordance
7.Is this a repair to an existing well-. E]Yes or InOo with MANGIC 02C.0100 or 15AArdW 02C.0200 WcHCons wdlon Srartdmds and that a
Ifthtsisarepat,hU out Am =iveUconstrucdonbtformadon and esphtfn the nature ofthe copy ofdrlsrecordhadbaenpoddedtoMe well oivner.
rcpafr under 921 runarlasecKon or on the backofthtsform
• 23.Site diagram or additional well details:
B.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 OW-1 is needed. Indicate TOTALNUMBER ofwelis construction details.You may also attach additional pages tf drilled. 4UBMITTALINSTRUCfIONS
9.Total well depth below land surface: o tS ( ) 24a.For All Wells: Submit this fomr.within 30 days of completion of well
Fo —1d,pleweffs1&ta11 depths{rdlfferent(—ple-3(a)200'and2@100-) con=cdon to thefonowing:, '
10.Static water level below top of casing: g 6 (Ot) Division of Water Resources,Information Processing Unit,
lfwaterfeWMabove easing use"/ 1617 r&n Service Ceater,Ratefpb,NC27e9-lei?
ll.borehole diameter. 24b.For Infection Wells:,In addition to sending the form to the address in 24a
;12.Well construction method: y�/¢/'Y above•,also submit one copy of this',form within 30 days of compledon-of well
(.a Well
construction
method.etc) construction to the foltowi°g'.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699=1636
13a.Yield(gpm) t� Method oftest: +�. �'T�' 24c.For Water Suonly&Infection 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: Ali Ibr:» Amount: 0 6t� completion of well.construction to the county health department of the county
where constructed.
Fomi OW-1 North Carolina DepartmentofEnvfmnmmtal Quality-DIvision of WaterItesomces Revised222 2016