GW1-2022-07701_Well Construction - GW1_20220811

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1.Well Contractor Information: I or Internal
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NC WellContmctocrtiffcatiOnNumber >o: 1.�tf D it. FROR a6iCompanyName I t TtnC[°YEsg hill2.Well U �2=t' )%Z tt' to. SConshtteonPermiti � r;rc n Octi EltCASINOR.fit1B
OhlTO gi �osedlbo ?:�ance.eta) ft, CIQiESs .h3•WellUse(checwelluse): hWaterSupplyW : R• n• tn.
Agricultural FROM �» '� `�'.�•:��:iir•":ist'g;2:,<e�:!!L~i'ir:d?,i,�'•1S;r•43
13MunicipalTublic TO DIAhn;7ER SLOlSIZE'
Geothermal(Heating/Cooling Supply) 0 R fG io Terctavess htAlERtpL pP Y) gap Water Supply(single). IndustriaUCommercIai � '
bri ation DResidential Water Supply(Shanxi) tc to
r18:GROUI�'�f. ,'.t•: t:ie•7t v._.; .. ,..
Non-Water FROM TO �i � .{> PrE �`k
Monitoring tt o f4 � � Ehtel tcEhmri oa&.v►tolmr
Injection WeII: Recovery
R d ev
AquiferRechge a Groundwater Remedietion
R iG
Aquifer Storage and Recovery
0Salinity$arder Fv-�AIVD/GRAVEI?PACIC a" Geab1E sue,
- Aquifer Test g FROM R TO AlATER►AL .:x�::.c:w�Et k� x��...... 'r•tu'.°ni;E OSt nawaterDraina a 3".. too
Experimental Technology Subsidence Control tt
Geothermal(C►osed Loop) -
f� R
Geothermal )'LTmcer 320.'DRII;l;�g
(Heating/CoolingReturti) Other( lainunder#21Remarks FROM I'OG aNachD di8oaalaheetii[n- r;. <.,
!` TO ESCR@7ION aoTor.hmdaets,aetltaeatr — 7•»•.IF.i r ii:.
4.Date Well(s)Completed: R oral
WeUM# n 1 G
Sa,Well Location: n
CffLLL.�/ - Ar
Faeili nerName D' -
t�, FaeUity IDP(ifappUeable) --ft.
Physical ��Ui e� l'�i G. Z p IL
Addmss Ctly,aadZip
County 521:R1a1ipRlfS:<„:k".'i
Paaelldea. - %,•:;.:.....ot3; ut}_"ice:?:�•s�cr?• h6eahoallo.(PIl�I)
5b.Latitude and longitude In degrees/atinutes/seconds or decimal degrees:
(ifwell field,onee1/atfiong fs suffietent)
'3-Q 22.Certification:
6.Is(are)the well(s)�rmanent or [Temporary Si
o Cati6ed 11 Contractor
7.Iis this a repair to an ex
Lvtin 8 Date
g well: Yes or �Ph� S ehts jorn4 l bat:by ea*that the tvdi(s)tear',
Ifthlrfiorepab;jtUautlarotvn tve(l eoartructlon b jornratton aaderplafn thenature o the "M 1SANCACM 0100 or ISA ( )eo+rstructad br andi t,
Or On f pYofOrLtmwtdlrarbaen IYCfCO2C.0200ipe1fCotrrnugion
drebackgjthlrjorm, pmvld�todrdne!loumr, '�a�a�ondthata
8.For Geoprobe/DY1•or Ciose'd--Loop Geothermal Wells having the You may use the back of this page to provide additional well site de
construction,only 1 OW-1 is needed. �m or additional well detaHs:
drilled- IadicateTOTALNUMBERofwelis conshucdoadetaUs. You mayatso Attach additional tar'Isorwell
pagesifnece nw-
9.Totalwell depthbelowlandsurface:_�60 S�MITTamTRIU^''OM i
FormvltlplewdlalLrto!ldaptbsly'd8erent +Vi,�
(aramp11 4200 o zwoO) (�) �� or All Wens,
10.Static water level below top of casing: tl a ��� Submit ibis fomt within 30 clays of completion of well
construction to the following:
11.Borehole
is is e t ring are+% (R) Dlvisloa of Water Resources,'Information Processtn
11.$archaic diameter; �tJ 1617 Unit Service Center,gal DUnit;
(in) . etpit.NC27699 I617
12,Well construction method:_ / 246.For Injection Weds: In addition to seadiag the form to the ati'
(Le.auger,rotary cab ✓'�, Y-�r/ abovq also submit one copy of this.form within 30 days of completion i well`
push,etc) construction to the following••
FOR WATER SUPPLY WELLS ONLY. DIvlsion of WaterResources,Unde
r etgrouad injection Control Program,
13a.Yield(gpm) U 1636 Mail Service center,gales I
Method of test. / giro NC 27699:1636
7` 24c.for Water Sunni &Infection Wells: In addition to seadin
13b.Disinfection type: p /�� the addresses) above, also submit one'co of g the fonti.to'
e °unt: y completion of'Well construction to tiro couay hog department within 30 da
where constructed h+ days'of
Form GW-I :.:..
Pamnent of dre county i
North Carolina D epartmeotoFEavuoamental ua .• Q liry-DlvisioaofWaterResomces
Rc*cd2-22 20I6
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