GW1-2022-06672_Well Construction - GW1_20220708

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1.Well Contractor Inf`o�rmattiion: q
c d' s/ ✓. A! �) I.61 C1, '14.'WATEFLZONFS'.
Well.CoattactarName T FROM 7O �;:^ DEStntiPHQV :t:5: `
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NC eU' ntmetorCetBficatioaNumber
§1S11OUTMCASING form " fvell� a" 'ble::�i;s^:: •',s
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CompaoyName
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MBIN ti'CASII�iGORfifIBING tlide"ofalelnsed�inobli .G3,<<.:k•raEQ1741%,2,
2.Well Construction Permit.#:_ �I — L !;t 71 FROM I TO Dr45MM I MATERIAL `
UstaU appUcabie svrUconstruction permits(Le.VIC County,State,Variance,etch
3.Well Use(check well use): ft. & In.
Wetersupply'Weu:
FROM DIM EM SLOT'SIZE THttUt1V6S3 MATMtU►L
�Municipal/PubGc 0 ft. ft. to.
Geothermal(Heating/Cooling Supply) 13Residentisl Water Supply(single)
Industrial/Commercial DResidential Water Supply(shared)
bti On Y1S�SRO1ITt.`a}'t{Ef: :;ltyG�lf ;n,Y e:. :X'3e�`iT � '• k:$7�:s`s a�i ti+YiiY✓i�':.
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FROM I TO .. MATBRiAL,:f F�YlpLACBIN@rr DBAMOUNT
Non-Water Supply Well: R j a
Monitoring Recov
cry n tt
Wection Well:
AquiferRechatge 0Groundwater.Remediation
A19:SAND/GBAVEi%PACK a""Ueebie xa•'. a+ ?wi:;si."�::�eaai';tu�:C,;a�elf'c�:4
AquiferStotage and Recovery 13Saliaityllarrier FROM TO iHA7ER]ALI IIY>pLt►CSIItENTNtE[HOD
_ AquiferTest. 13StommwaterDsainage & ft
Experimental Technology 13Subsidence Control ft. R
Geothemtal(Closed Loop) �Tlacer M:DRiM,WGLO(i dttaehaddlHfin`albbebfsi[' �+t;;;;��;t� 1 f•*;S•
Geothermal `a oling Retm) Other( iain under 0l FROM 'M DFscRtertON min tea seuheeeic etW
t3 ft ft. +!;
4.Date Wells)Completed: ,Z Z WelI ID9 ,2 tt ie i
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Sa.Well Location: tt
FaotUt ownerliame _ Facllhy My(ifenUmble) n• 1t•
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PkmkalAddaw.City.andZip C7
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ill::'r'n2{=:6.'•"-."i4i;�.��tii�rs:•:nisi':3YJ�t.;:.•4u�4::et3?'�.'�:ti';., I.
County Yan:elldeneeationNo.(PUO pii �Sl i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field.am ladlong to anfcient) L J 22.Certi6catioa:
6.Is(are)tile wen(S) ernranent or Temporary Ss�6ofCadffedW Coutwcmr Date Z 2
�_✓ BY slBeb+E ddsforuq 1 AMhY care that the weU(� ►sa(iverr�conducted fn accordance
7.b this a repair to an existing well: DYes or !� with 1S.f NGICOZ.0100 ar1SANCAC 02CA2001redCo)u&mwon&mrdmdsmud that a
.fd*rsa r4pdr.flUoutlmotm sveUeonstmvdan btformatton mud oWlaln thcmture ofthe ropye*bmcoMAarbeetiprovidedtod ewell owner.
repatrunder#21 remarlamRon oron die backofd*jbrm 23.SIta diag
ram or additionp.l well deit;1h.
8.For GeoprobeMPT or Closed-Loop Geothermal Wells having the SaML You may use the back of this'page Wpm a additional well site details or well
construction,only 1 GW 13s needed..Indicate TOTAL NUMBER ofwells construction details. You stay also attach additiioaal pages if necessary,
dn7led. S_IIBM]TTAT•�cTRUC1TONS �
9.Total well depth below land surface: 24a.For Aft Wells: Submit this form witiin 30 days of I Fortmdtiplesve/Is/rstalldepthslfdl,�erart(examp1�3@200•arrd2Qa 1007 (�) �r11p lion.of Well
construction to the following:
10.Static-water level below top of casing: S UP Division of Wafer Resource's,Information Processing Unit,
lftmterlevalb abovaanln&use"+" .1617Mai1ServiceCenter',RaleiptyNC276991617- `
1L Forehole diameter. (iri,)
24b.For Infection Wells-.In addiddn.to smft the fort to'the addtess•in24a
12.Well construction method: red tg e y above+also submit one copy of this foam willim 30 days of"lotion-of wad
(te•809r rotary.cable,directp-%ere-) construction to the following: }
D1vlslon of Water Resources,Undeigromid 14ectioa Control Program,!
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, INC 276994636
Da.Yield(gpm) 3 Method of test: 24c.For Water Suonly•&Infection Wells: f—addition to Ben UU the form to
the addresses) above, also submit one copy of this form within 30'days of
13b:Disinfection type Amount: o'Z . completion of.'well construction to the,
county,health depart%cat of the,county,
where constructed.
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FormGW-I. Noah Carolina DepartmentofkwdmnmentalQaalby:DIi*n.ofWaterResouuees Revised? M16
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