GW1-2022-09336_Well Construction - GW1_20221007

WELL CONSTRUCTION RECORp(GW.1)
For Internal Use Only:
1.Well Contractor Information:
Act CYe,4f+ I- I4.-'-WATE1t!-Z0N0!.
Well Contractor Name FROM I To it DESCRIMO.N
— q5q5-A
NC Wall Contractor Certification Number
ur6nn 61bley
-1&0 CASING.1formul-�-9�aswo It�OLuq
FROM
Pu rVQ9 �n ----]—TO - DIAMETER •
T, CKNESIS MATERIAL
Company NVWo_ IF ft. 43 0 ft. 6,US In. 841 tY
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ig"Bit�ffiASJXG OWTUDING11liedth in WOOD).
2.Well Construction Permit#: I I I
-t 14.0�X7.7- I D I A 114 RT V RATI 1,1r.K N X S 8 MATERIAL
List all applicable well const,71cliollps,71,115(I.e.UIC Callilty,State,Valancal Cie.) rt. ft. In.
3.Well Use(check well use): ft.
ft. In.
Water Supply Well:
FROM I To I nVAMi�
Agricultural E)Munfolpal/Pubilc -- — run 1 11-01 SIZE THICKNESS V MATERIAL
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in,
ft. ft. In.
Industrial/Commercial lRosidontial Water Supply(shared) 40,2R0JO1'
Irrigation FROM TO MATERIAL EMPLACEM W FNT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. W
3 L/ tjog
Monitoring =s
E311ecovory ft. ft. I
:)Aquifer Recharge' 13GroundwaterRemedistion ft. ft.
t3Aquifer Storage and Recovery 13Salinity Barrier -10-�SAN - . . - .
r LVIR—OM I TO MATERIAL ..EM1`tA_C_F9F_,9�M IST'H"OD
Aquifer Test
OStormwater Drainage m r
Experimental Technology oSubsidenco Control ft. fL
Geothe6al(Closed Loop) DTracer ....... ...
I P FROM I To e aeot 7,Geothermal satin Return) Other(explain under#21 Remarks) DESCRIPTION(color,112rdneu.10111rock brpe,grain s1w,Cie.)
4.Date Well(s)Completed: well ID#
So.Well Location- ft. ft.
ft. ft. A-Z
Acility/OwncrVema
0 Facility IDN(i1'applicable) ft.
-AbrCAMS CLI44 Moore-Ad rf ft. i
Physical Address,City,and Zip ft. ft.
Alk 11 NAIR
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees.
(ifutell held,one lotilong is sufficleat) 22.Certification:
35,3)07F( N --2z..060 G 6 W 1h I
Temporary Date
6.Is(are)the well(s)OPermaneut or SigaRture ofCcilified Well Contractou
By signing Ihla jorm,I hereby lUy that the ual/(sJ rras(were/constructed In accadonce
7.Is this a repair to an existing well: ©Yea or4bNo w4elt 15,4 M.W 02C.0140 or eel ISA AICAC 02C.0200 Well Construction Standards and that a
0111s Is a)-iWaff-Jill Oil/kt011ln Ivs//construction hilbi motion andeAplain the floull's ofthe copy oll0th iveardhas bean provided ia the ivallosvnep.
Vevolr under 1121 tw1norks section or on the back ofthisform.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closod-Loop Geothermal Wells having the some You may use the back of this page to provide additional well alto details'or well
construction,only I OW-1 Is needed. Indicate TOTAL NUMBER ofwall's construction details. You may also attach additional pages IfnecossaLy.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5 00 24a. For All Wells: Submit this form within 30 days of completion of well
Ror mulliple wells/it/all deptlys I(different(example-3@260'and 2@100') construction to the following:
IQ.Static water level below top of casing* /00 (ft.) Division of Water Resources,Information Processing Unit,
IfIvater level is above caslig'.ass,"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.* I
Borehole diameter: 24b.For Infection Wells: In addition to sending the form to tho address in 24a
12.Well construction method; a,.4.,.,, above,also submit ono copy of this form within 30 days of completion or well
(I;e.auger,rotary,cable,direct push,etc.) V construction to tho following:
Division of Water Resou a,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cqnter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water SunnIv&Infection Wells: In addition to sending the form to
the address(es) above, also a,ubmit one copy of this form within 30 days of
13b.Disinfection type: Chl&r in-f— Amount: A C,r., S completion of well construction to the county health department of the county
where constructed.
Fortnow-1 North Carolina Department ofErwiroumental Quality-Division of Water Resources Revised 2-22-2016