GW1-2022-09595_Well Construction - GW1_20221021

:LL CONS'TRtTMON RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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Well t omraotor Ideare FROM '-M D&4CR'MON
NC Well Contractor Certification Number r ILft
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& f� FRO TO D1AAtI CFa2 , TAiCKNFSS MATBRW.
Company Nam { ✓ C Z r rig
D/ j ry / c� 16.1NNER CASrIt�flx 3 vetiver; tear mal cJe;ed io$ E:>:. ..
2.Well Construction Permittli / rn.t l)t'�c2c( —/6o7. I TO 2?tA ILL THICKNESS 1tL1'f0M.
JAO all applicable well construction permits(i.e.UIC,Couno.State.I'm4ance.,etc,) ft• fL to
3<Well Use(check well use): n re to
Water Supply Well: 17.=t;GItREN. ,• .._; _ . . .... .� a: .
FROM TO I DIAMMIR SLOTSIM THICKNESS MATERIAL
0Agttiicu#tural ❑Municipal/Public (L 1t. In. } 771! .•
0CWthenmal(Heatingi poling Supply) OResidential Water'Supply{single} fc ft In
[IbuletstriallCommett ial residential Water Supply(shared)
t8.GROt1T rfn c, ..._ �. .,�•77
01rri lion DWlells y 100,000:GPD FROM to MAT£ 4t EMPLACEMWa METBoa&AA OU
--
Qlvlonitoring ORecovery rt. n
Injection Well:
ft.G)Aquifer Recharge 00roundwater Remediation R.
'tpSANDIGRASrE1 t'ACit ft: "]tcatiic . . ..
!OAquifet Storage and Recovery OSatinityBarrier FR:,OM TO MATFRIAt EtitPZAo rExrAtKrRQo
OAquifer Test OStormwater Drainage lJ n Y
OExperimental Technology OSubsidence Control ft, R
OGeothermal Closed' ittiich= idhlcuat beetc!f
R=
( Loap) OTracerO:;DRfCLIIYG
OGeothermal{Hestia C.00lirr Return) []Other ex lain under kI Remarks FRO'*' TO VESCJZ2MON color hardaem saftaSkIM Vale
4.Date Well(s)Coralpeted:, Well ID# "
it it Zrt 5 Well Location: R' IL
4
k n t""-J= ,,
Facility/Owner Name / Facility 00(ifapplicable)
2022
GL 1..�y"��° t' Y f !
Physical Address,City,
City,and Zip rt ^.%•0i��'�
9 i W�
31.ItEMAIiI{S:
Coumy Parcel IdeiuiCt artionNo.(PIN) �
56,l.atltude and longitude in degreesluthintes/seconds or decimal degrees:
ofweli field,.one iluiony+is sumc`iant)
22. tificatio
j�
N ty s W
6.is(are)the weil(s): ( ermaoent or O1'emporary a9kre shim rm l Here ified ell contractor
ti:�t by rfY e well(s)was fitw l construded in accordance with
7-Is this a repair to an eldsting erect: ljYes or 10 1JA 1VCdC 02C.0100 or 1 SA NCIC 02C.0200 Well Construction Standantt and that a cops,
lfthts is a repair,fill out known well cone ttdion h jorrnatlorn and explain the nature of the of this record has been provided to the wail o%wr.
repair under#21 remotks section or on the back of thlsform. 23.Site diagram or odditioaal well details:
S.For GeoprobeWPT or Closed-Loop Geothermal Weill having the same You may use the hack of this page to provide additional well construction info
construction,only'"GW-1 is needed. Indicate TOTAL SOMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled. 24.SUBMITTAL INSTRUCTtOAiS
9.Total well depth below land surfatx: 1 C 'T J (fr
For multiple welis list all d4,rhs{rdierent(example.3@200'and 2@1011) Submit this GW=1withlo 30 days'ot well completion per the following:
1Q Static water laid'below top oteasingt UP24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifw0urtentisaboveeartn�suss`+^ �I ) or Injec
tion ing Unit,1617M9G,.Ralcigh;NC2 7699-1617
11.Borehole diameter 24b F
. a. n Well!:Copy to DWR,Underground Injection Control(rUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well eonstrurtion'method; 14dfi 24v'For Water Supply and Open-1 Ion Geothermal Return Wefts:Copy'to'the
(i.e.auger,mussy,cable,direct gush,.eta) county environmental ea tb departmenvof the county where installed
FAR WATER SUPP Y,tvFLLS ONLY: 24d.For Water Wells producing onr.1_1000 GPD:Copy to DWk GGPCUA
t3a.Yield'(gpm) ._ /r10a Method of test. "+f Permit Program,1611 MSC,Ra�erg 699-1611
13b.Disinfection type. Amount:rrr 0.-y,.,
Form 43W-1 'NOM Carolina Department of Environmental Quality-.AivisiDn of Water Resources { Revised 64-2018