GW1-2022-06422_Well Construction - GW1_20220706

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f.Well Contractor Information: 1
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;,. s'k. w R.:Re.� e? • . /,n. u.tvi.:t i: t
Well ContractorName FROM TO DESCRIP7'itN
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NC We ConlraetorCeKtHcationNumber
�/f A 9 /� �..� 313fO1TCER:CASING torffi'in tt�`ed welt OR'LIIVER e"IIm"'61e l: i7s..�i%,•3r::'fio
C 1 FROM TO BLAMER! i TAU dlATSaW.
CompanyName �: iG e) 'L O
t14'IIVNEIt'CASII�IGORlrUBII�iG fIi'" ela"ed4lou'?31C..,ix'2JhaPa
2.WeII Construction Permit#:__�//L t FnoM To arAatt IS-: huT
List all appIlwbfe veff cons*wdon permfts(Li.Mr.Cow*Stag YaTma ee.de.) ft. R. in.
3.Well Use(checkwell use): ft.; ft. to
WatarN-5-1yweU: t17.SQREEN�t A! i Y. 2e�3S1d1L}Yti
FROM TO IAINSfER SLOT THr S
griculturai �MunicipaUPublic 0 & ,
Geothermal(iieating/Cooling Supply). Residential Water Supply(single)
Industdal/Commerold OResidendal Water Supply(shared)
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FROM TD MATERiAL EMPLACBafF11r OD&AMOUNT
Non-Water Supply Well: © fa 3 iG
Monitoring [3R�
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Injection Well:
wferlteah R
A9 � � �(3round�aterRemediation • .
uiferSro ry f.19:SANDJ VEfiPAGK 1i'"iteable N ice:23t•�::aCd tc': ' .>'
Aq rageandRecove �SalinityBatrier FROM To MATERIAL EMPLAt�a n
uifcaesi 13SromrwaterDminage R ft:
Experimental Technology 13Subsidence•Coutrol it
Gcgthemtal(Closed Loop) D17ratxt i20.iDRt7:LWG dlfaehadditiGn`al8beatltiaeebsiii' '. tsJv u: ,:
Geotitet 1 l CoolingRetum Other Iainunderd2lRemarks FROM To n ox eom tuiidaesssotV�oer: ..
p m ow
4.Date Well(s)Completed: ,ZZ 7i WeU DNf_• to it. �� 1
Sa.-Well Location: C ft.
Fsalt //Owner/N�ame _ p FaailltyIDO(ifapplteable) ft. :it.
Pl�y3tcalAddnx4City.and2ip ft- ¢ Pl, eP1 fir^ UrVW
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CO-W pamelIdentifMionNo.(PRO.
Sb.Latitade and longitude In degrees/minutes/seconds or decimal degrees!
(ffwellfield,one ladlong fsaufficrent)
r 22.Cafficationt
3sS� N _
6 h(are)thewel*Ofermanent or Memporary ofeatit["Well combactur Date
S%for+n.1 hereby eve that the Ive f(s);ysas(were)contracted&accordance
7.Is this a repair to an existing well: [3Yes or [3� IJ.tNCfC01C SIOO or1SAMCO2C.0200 Wed Conraualo S*On&*and that
trthfsfsarepair.JM out Anownwellcant"ctianWannaRon and atpfafn the nature ofthe CW'elhfs—AfhmbemprovNedtathasmdowfer.
mpafr under#21 mmarkssection or onAs back gmrsform.
23.Site diagram or additionpi well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You maY use the back of this page to provide aaftional well site details or maU
construction,only 1 GW-1 is needed.Indicate TOTALNUMER ofwells construction details.You may also attach additional pages If necessery.;
drilled: ,
831BMIT1'AL IN3'i'RUCI'IONS
9.76talwell depth below land surface: �S6 (it:) 24a.For All Welts; Submit Ww fiorm within 30 of Completion of well
Fornralllplawed/sllrtaffdapths{/'dj�arard.(eson►pft-3�T00',andIQ10D? P
r , constructiontothefollowiog:
10.Static water level below top of casing:_- 00 Division of WateiResources,Information Proceaaing.Untg ,
lftrater/avaffsaboreem/rr&ose+'
1617 Mai1SerAce'Center,Raleiph,NCZ7699-1617,
11.Borehole diameter. . (in.) 24b.For Infection We11as In addition to aen diog.ths form to the address in 24a
12.Well construction methods XIAI above,also submit one copy of this fomn within 30 days of eompletion'of well
(ta.auger.rotary.cabte,dkcctpnsu,eta) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division pf WaterResonrces,Underground Iyjection CcutrolProgram,
1636 Mali Service Center,Raleigh,NC 2709=1636
13a Yield(gpm) ! _Method of teak t 24c.For Water Subnly&Intectio3r Wells:;In addition to sending the Iona to .
the addresses) above, also submit one'eopy of this tbmt within 30 days of
13b.Disinfection type.- ` Amount: 0 completion of'well construction to
county hisith tlepartmeut of the county
whereconstcucted.
FasmGW-1 Nast6CamtinaDapartmentofEwAmnmmtalQualily•DIvbionofWataResomaes Itevfsed2,22.2016 !!
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