GW1-2022-07475_Well Construction - GW1_20220810

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1.Well Contractor Information: ,>.
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WATERZONES';;= i L"s�*.i: •"••s�.:` ::f.r.:?ir':t;5::' :';':is>:i•.'::
Well ContmetorName M TO DFSCRIPT EN.
V42 ) y1 M ft.
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NC We lCoatractorCetttficationNumber
0UTER:CASING formnitlFa4e'dweR a"'livable ;.';6e6 s r D G , M TO DIAMETER TH CEMESS AIATE1t1AL
Company Name TA fL (' ft. to. Doi
r16'INNER'CASINGOR47JBING: lUthetC�91l16tld.1a ? Y'C..i!ti:t'iiA4.,:)fKA.:1�,
2.Well Construction Permit#: �/fL i FRoIV - To DINHEfER TBICI�IESs 11tATERW,
List all oppReable wdl eonsavctlon permits(Le.=County.Stara YarlaneG etc.) fL ft. in.
3.Well Use(checkwell use): R. tt. Ia.
Water Supply PP Y Well: ;b17:SCREENs;F•t.�,isi<'`•'tt+r'�.�:a!:•^.l::i'J2r<i'.'S5:•rw:`4�.�,.gt.,ySTi: a..C<8w`s •.sir"ci;:`;S4LK�'tyS
Cultural FRO I TO DIAMETER SLW31M I TMCENESS btATERiAL.
�MunicipaUPublic fL hL
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL fa
106
industdaYCommercial oResidential Water Supply(shared)
Irrigation YoGMRotrr�To r;.'.;• 5',f 7/J.ia•Y+i4ti i:c :, tom,.,,. •�',�9:v:is �...,:•.
MATERIAL EMP
Non-Water Supply Well: CIVtENrMETEItOD&AMOUNT
© R 3 t4
Monitoring Recovery "t
Injection Well: R R
AquiferRechalge E30roundWater Remediation
Aquifer Storage and Recovery 13Selint'tyBarder f""'SAND/GRAVE[sPACK a 'IIe6bie r! fc: rein i'wu i,_=u; rw ti ,
FROM TO MA7ERL►L
EMEIACE 11MM METHOD
AquiferTest [3StormwaterDrainage R ft.
Experimental Technology oSubsidence Control n n
Geothermal(Closed Loop) ,Tracer ''S20.'DRILLD�IGLOG slts2haddifidn'nllLeetii[rieeni6 ' *f;, [�: +;:J.;!;�;,•.; ;.
FROM TO DESCR�7ION eefer.Eaidaers.son/roek ssr_f.t}..,x„�j,
Geothermal eating(CoolingRetum) Other( lain under#21Remarks) eta
t` 17
m o 1
4.Date Well Z s)Completed: 'Z • v Wen" /7 m fL w
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Sa.WellLocation: c� ft.
Fbcility/OwnerName - Facility IDll(ifappUeable) R ft.
PhystwlAAdddasMCity,and tip f` n,
���rL L=3�L`"��� Q� S21:REMARKS i?i',:.::5:'. 'I.S:'^• SJh.:rnt'ar7 i�`:'F e�•.$;`.sytt,1��1•:4I3.'�•X?x31: _,• _!
County .ParcelldentiSwtioaNa.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decl al degrees:
(Ifwell field,one ht/long h sufficie t) + 22.Certification: L r S�
w
- Z7" Lit
6 Is(are)The wen(s)
M'lrrmanent or [Temporary Si ofcerti6 ell Contractor Date
8 n ing this jornc r hereby eert(fy that the wdl(s)war(were)tonsarected in accordance
7.Uthisarepairtoanexistingwell: E)Yes .or e� 116ISANOICO2C.0100orISANCAC;02CA200IrKConsteuctronSrandardtarrdrhae{r
1jthisisarepair,Jtlloutknowawelleonstmegonbrfarnrattan and esplain the nature o)the roPY00fiOrererdhatbeenprWdedto the wellowner.
mpa(runder021 remarbswdon oronehebaekojehisjorm
23.SIte diagram or additional well'details-. f,
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of thin page to provide additional well site details or well
construction,only 1 OW-1 is needed. Indicate TOTALNUMBER of wells construction details. You may also attach additional pages If necessary.
dn'Ued:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: YS'a
For muftyle 24a For All Wells-. Submit this form within 30
ttlplewellslistalldepths tjdiferent(examplo-9®100•mrd2Q100) (R) days Of completion of well
i
construction to the following:
10:Stalk water level below top of casing: (ft) DIylsion of Water Resources Information Processing Ualt,,
Ijwaferlwells above easeng:ttte� ,
1617 Mail Service Center,Raieip),NC 276991617
11.Borehole diameter: . 1 (In.) 24b.For Iniectlon Wells; In addition to sending the form to the address in 24a
12.Well construction method:_I- 4&cV above,also submit one copy of this form within 30 days of completion-of well
(Le.auger.rotary.cable,dk-tpusb,etL) construction to the following:
FOR WATER SUPPLY WELLS ONLY: DIvision pf WaterResources,Underground Injection Control Program,, i
1636 Mall Service Center,Raleigh,NC 276994636
13a.Meld(gpm) f' Method of test: : 1, 24c.Itor Water Suonly&Iniection Wells: In addition to sending the form to .
13b.Disiafectioa e. L' the addresses) above, also submit one*copy of this form within 30 days of
type: Amount: t7 completion of well construction to'the county health department of the county
where constructed.
Form GW-1 North Carolma Department ofEavircamental Quality-Division of WaterResoumes!; Revised 2 27.2016
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