GW1-2022-07447_Well Construction - GW1_20220810

♦t L'LL IiVl\►711\V<.11V1\iW\..ViW�IJ���it I ror llltel'nal use Only:
1.Well Contractor Information:
.•14.WATERZ0NES:':
WellContractorName FROM TO DESCMFrICN
fL X01) - 1 4�.LJ ry ! 2022 it. 4
IL
NC Well Contractor Certification Number
U d �15:OUTERCASING fo"rmnlfitated.w R to"'IIcsble
FROM TO DIAMETER I TIIICIQIESS bATERIAL
',�s:1��P"'�,.9-•,•�c,c� 9 tr. fa ln.i j Q' I 'vL
Company Name ar -
r16rII�IIYER'CASINGOR:TUBING: eiitiiermslilnred4od :.?:;.;:� a<:i:,:::i .,'•,+c:;„::; I
FROM - TO DIAMETER TMCKNESS t MATERIAL
2.Well Construction Permit#: � �7�1
List ail applicable mvell construction permits(Le.ENC County.State,Yarla=6 etc. ft. % io
3.Well Use(checkwell use): fL ft. In. II
Water Supply Well: i17.'SGREEN:cr' •;'::; S. ui i?)ar"r'rf:i' 4>'.'•','ss?i{i w^> sk',i;;: :'•z:3.+1 r
FROM I TO + DI411MM I SLOT5I2E,I`THICKNESS I MATERIAL
..Agricultural 13Municipal/Pubtlo O & tt: im
.. Geothermal(Heating/Cooling Supply) ORMIdential Water Supply(single) R
lndustrial/Commercial E31tesidential Water Supply(shared) ,�:,f,.....-
::1&GROUl'r=i '• s:.?:,.<....::-;Ys:y
lrri ation FROM TO' MATERIAL EMPLACE MENTMETHOD&AMOUNT
Non-water Supply Well: IL fL
•r (J+
Monitoring [IRecovery ft. ft.
Wection Well:
AquiferRecharge DGroundwaterRemediation
391AND/GRAVECPACICa IiesblE .�w:':iL<„;S +e a-xS.!:;`'ss •r,'':"+
Aquifer Storage and Recovery E31ialinity Barrier FROM To MATERIAL I EMPLACFA ENT METHOn
AquiferTest OStormwaterDlainage ft.
Experimental Technology 13Subsidence Control fa &
Geothermal(Closed Loop) QTracer 'i20.'DRELLINGLOG fiiietaahadditlo`nalbb& ffii
Geothermal(Ileating/CoolingReturn) Other( lainunder#21Remarks) FROM TO DESCRmnON colorhardaesr.seWnwk ere
R IL R
4.Date Well(s)Completed: -Z2 Well ID# 14Zp fL & •e
Sa.Well Location: D' IL
RcMty�/OwnerName - { Facility ID0(ifapplieable) M R'
7 6 s .E�fl >'J.C. z$'d�� ft. R.
Physkal�-Address,City.and Zip f�t�.�y� ft.
—+��7'�dR9 ?2itRIIKARKS�� �_l!.] ���Z%4.iirl+.:ii:: ':.(�lt�.` a3�_.�i}✓t iY::• ::}'�
Connty -/(\L -Parcel IdentificationNo.(PI )
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ht/long is sufficient) 22.Certification:
6.Iis(are)the welt(s)�rmanent or [3Temporary si of '4y signing this form,I hereby eere that the ivdt(s)was(were)constructed in ateordanee
7.Is ffits a trepaic to an existing well: [3Yes or IgNo idth]5ANGIC 02C.0100 or ISANCAC OIC.020D Well Comimetion Standards and that h
.(/'this is a repab;fill outAnown mvell construction Wormation and esplala the nature ofthe eopyofthts recordhas been provided to the well mvner.
repair arler#21 remarks sec ion or on the back ofthtsform.
23.Site diagram or additional well details:
S.For Geoprobe/DYT of 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 TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
wed; SUBMITTAL INSTRUCTIONS
i
9.Total well depth below land surface: 7 00 24a.For All Wells: Submit this form within 30 days of completion of well
For ma►tlplewd&list atl depths ifdt faart(examplUT 00'aed2@100) Construction to the following:
10.Static water level below top of casing:_�� (it) D1visIon of Water Resources,Information Processing Unit,
lfwaterfevellr above caring.rcre"+" 1617 Mail 8ervlee.Center,Ralefplr,NC 27699-1617
11.Borehole diameter: (in) 24b.For Infection Wells: In addition to sending the form to the address in 24a
ii above,also submit one copy of this form within 30 days of completion,of well
12.Well construction method: Tr Y construction to the following.
(fe.auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: DIvision of Water Resources,Underground Injection Control Program,
/ 1 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) ,� Method of test: r ! "T 24c.For Water SLDDIV&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 i/ Amount:---&G O Z. completion of'well construction to the county health department of the counT.
where constructed.
k
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised2-22 2016
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