GW1-2022-08129_Well Construction - GW1_20220906

r -
'41V3ELL C0N5T'RIJC'n0N RECORD(GW_-!D For Internal Use Only:
1.Well CwtroeWr Itf''rrAmaadon:
f 14 AO /
Wall Contractor ter Name FROM TO DESCR11MON
R R
NC Well eu actor cartiseazioa Number oum. Ca
Company Nave OR TUBM
2.Wall Causbraction Permit N: r 4,60 d7 FROM I To DI&AMT R I 1'CKN1=-- I MATxalAL
Ltet all q*aable wdl confoucdon pembs(Le.U1C,County,Stare.V-ia—,ere.) ff 1t in.
3.Wag Uae(eb xk well arse): tt R �
Vk`aNr Supply WaJ6: 17.
To D1AMCM 1"I's17a TVAVLL
ricultuaal �Mufficipa!(Public fL ft. W
GeoftsmAl(Heating/Cooling Supply) 01tesidential Water Supply(single) a, tL ----
Industrial/Cuanmetoial Residential Water Supply(shaved) IL GaGUT
FROM I TO MATIML i TMPLACUMF.N T NtYYHOD A AMOUNT
Now-Water Supply Well:
t!tfit. it. �— I
� [�� Ro covery ft
�� M R
Aquifer Recharge DGroundwater Remediation ---
�r1f+1.lM�C
Aquifer Storage and Recovery Salinity Barrier FROM I TO I 1KATMAI. RMFIJtf EIY[eKT Mi;'ISOD
Aquifer Teat 13Stormwater Drainage % ft.
Expeffirriental Technology 13Subsidence Canttai ft R
Gaot wmW(Closed Loop) Tracer 29 la3Qf(I LJ19+G 1.00r attasd S
lie getum Other lain under#21 RetnmSra mom TO DFSCRiIimm rolsr saw" �—
ft. tt.
4.Date Well(s)ComplotMd. Wen IDM _ R R'
32.Wen Lemmdon:
F�/Chi�omName Feciliry IID*(if applicable) - R R Y,` A s yV Z.& F
ft. 2022
P6yeical Adder.City,and rip R h.
6DG 3� 1 L IInr.
County Paten lie["t ation No.(P" _
ft.Latitude and longitude in detpreea/minates/secoDds or declmitl degrees: --- - -- ----——--- --
(if well fickd,one WVIDDS is sufficient) 22��CetOli€catlom:
Adz N ---,-W �A')./, -
6.la(are)the�(s) Permanent or Temporary sigoatvn of Certified web Contatu krr Date
By.sigwg this form.I hereby certify that tie w dl(s)xas(were)consume tad is=ordance
7.Is this a repair to as existing wen. [3Xes or�o with I SA 14C.4C 02C.0100 or 1 SA NCAC 02C.0200 Well Conrtna:uen Standw,&and that a
/JYhfr Ls a rrpelr,l4lJ out known well corardw:Jtoro infornaarinn and ecplain the rraatre of the copy of Ws—d has been pmvided to the wrdrfi ol'mw.
rgwir wrier#21 remarks swam or on the back nJ'rhtr form. 23.Site Wagraw or additional well detans:
S.For GeoprobeMPT or 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 I -1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1L-FIOPFS
9.Total well depths below land surface:_ � 00 24a. For An Wits: Submit this form► within 30 days of completion of well
Fop n*40k we"' Jlst aU dvou U'3oercnr(exanpie-3(ay206'and 1(arZ100� COn€trlrCti9ff W the following:
10.Static water level below top of easing: (ft.) Division of Water Resources,Information Processing Unit,
if waw level is above cal tg,we"+- 1 1617 rig"Swvite Center,Raleigh,NC 27699-1617
11,11orebele dianwier u/ I� (10•) Z4b.For laiection Wells: In addition to sending the form to the address in 24a
above.also submit one copy of this form within 30 days of completion of well
(Le Wap tMary.Cable. method: construction to the following:
(Le.roger,rvmsry,cmbk,direct mush,etc-)
Division of Water Reaources,Underground Injection Central Program,
FOR WATER SUPPLY WE11.9 ONLY: 1636 NW Service Center,Raleigh,NC 2709-16%
13a.Yield(Rpm) �l,e Method of test: _ 24c.For Water Supply da Inlection!Wens: In addition to sending the flare to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: — Amocuit: - corrrpletion of well construction to the county health.department of the county
whare constructed.
Form ow-1 Nodh Carotins Department of Eavironmenta:Quality-Divisioo of Water Resources R&Mscd 2-22-2016