GW1-2022-09791_Well Construction - GW1_20221027

Feb 1519 45ASp ClearwaWf WellArming
WELL C TIDN ILECOR3}{G'W�1} Fnr Intemnl Use only:
1. .11 Contractor Information: -—----
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Weil Cantraaa Name:
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ar t atificnGo 16 O1T1 ER C�IIVG forptoitl ORLi+lERR a MATERIAL
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Compal yName 1d.IMER CA91Nto WR flt81NG DtA rntct�s NATEnLIL
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x.Well Construction Perrall#: fe. R In.
0o alf applicable+ue11 eNuInIdINI parntai(1.1. Vic,cmmry.Stair.Varlan:tti cr-) in.
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s.1;Vell ille(check well use): t7. $� D AM&T69t SGOT9V.6 THICKNESS MA?aIItAL
Wa ter SuPPLV Well: om To
Munici aUPuhiic 1t• ft. i
Agriculhlral p O
(ieollicnnal(1•Ieating/Couling3tlpply) esidential Water SuPply(tingle) tt. to in
�Residentfai Wafer Supply(shared) 18 OUT
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DanM MA'i'ERrn1. SMPUC6MC.•7Tat. D&AMOtIN'r
Irrigation
Inn% nter Supply Well:
A4rntitaring
Recnvery to fr
Injection Well: it• it•
Aquifer Recharge GroundwatCr Remediatirm
19.3ANIl/GRAVSLFIICK tfo Ne 11terL10EINlIIhTMiCrltOn
Atluifi r Stomlto Md EZectrvcrS' �SaGnity Barrier eaoM TOO ►� T IhL .,--------
flL IL
Aquifcr Test 13St armwater Drainage
i�,5ubsidence Control IL
Experimental Tcciluoingyr t..r
2tk 1)RlLLING 40G sitrtrltatldl ema8110M o if ticerasart+l_
Geothermal(Closed Loop) [)Teuer 2&Bl TO D rear tatrlrator turefaes.rra(rotktYPr aralnstu,slal
(ieothenuat Reatin ooRnR Rcntml Other( lain ttndc(921 Remarks) I
4,date Well(s)CoMpleted: —z`3"" Well 10P it. ��f G lrLlitir
p rt. p
51a.Well Location- 6a I�qw ja u ft. �,rn• `1,��
F;ICIIiW0%X++erllama Facility IDU(ifamlicable)
P sinol Address,City,and 7.ip
-y`� --- 21.pEMARK6 OCT
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Comity � , pamcl identification No.(PIM) I
SI).Latitode and longitudeindegrees/minutes/seconds or decimal degrees; J+7K7wt+lrtu: �] rip
(i�.veltEclO,caS180001Lissu irimt) 4 ;' e I tion;
Signnmre nt'Ctstific+t'OVetl Cnntraaor �O
fi.!s(arc)the well(s) Pcrinanent or ©ITempnrarg
Lip stivliap,dux,;filed
!hrrrhv t met h:Thai the n ell(..j suer fwcrra caanrucreri fn aCM da!zCe
7.is this a rcpairm An existing welt: QIYcs or Nocorn,l3a MLaC 02C.D100 or 1SA N(.AC.02C.'.0100 WirilCorntrrrrcmnr 11andard,and Am u
;+'rl,ivis:impairfiill rhe+ur)1errI?frha tnpyaflleF.elr+rardhoc7�PCApMl�tdr�ltnrla'rue/lmN1Cr
r pair under il21 remarkr.secann or on Aar hart'Of lhixlan"e• 23.Site diagram or additional welt 411181 9:
8.For Geoprohe/llF C or Closed-Luny Geothermal Wefts having the same 1'nu mom'use the back of this page to provide additional well site fti or tvrtl
tx nslmcdian,aNy I GWI is needed. radiout4 TOTAL NUMBER Of.vrlls
construction tictaiis. You may a154 attach additional pagss 1f 7reccssaty.
drifted:,..._ _.�.._--.. �. _ �r,,.aaliy►7`nitl'TiQNS
9.Iratal wall depth below land surlaec:,.____�__ r (R4 24a. 16or�aN Vdells: Submit this fo"tiviiltin 30 dads of completion of-.veil
1%er•rnulrlptr wcllclitr all d.+prke ifdrgcrnnt(cxnnnle-3 ,,?(Kr'ond 2010171 construction to the fallalrfng:
]0.Stntle waterlevel below top Greasing; (fL) Division ofWater Resources,Information Processing Unit,
if erneer towd Is 0ime rarlrlg,wee/","1 1617]9Uf1 Service Center,Raleigh,NC 27b99-1619
1i_litrrcbotrdlnmetcr, tl/ -�f o•) 74D.Fnr I copy
addition to sanding the form r to dia of w Il
in 248
:ilrovc,also submit one of this form within 30 daysof comp)
etion 17.Welt eanatrnetlne method: ��!�ry� construction to the following
(i c,m,g=,mtaq.cable,direct push,etc.)
Aivision nfV4ater ReanurccR,ilndcrgromld igjetion ContrnllProgram,
FOR WATis'R SUPPLY WFLL9 ONLY: 1636 Mail 3erviceCcnter,Ralclgh,TYC 276994636
13a.Yield WPM) Mcthtul of test: _ �� 2 is 1'ar y►aW ter SuDDI.&inie>±Htin Wettm In addition to sanding the farm to
die addres(es) above, also submit One Capp of 11119 focal willlin 30 days of
13b.Disinfection type: Amatmt: completion of.vdl consuuction to the county hoaith department of the county
where anttstnlcted.
Itarnt C:tk-! Nord,Carolinarkpnnment of tinironmmtal Quallty-Divistor)of Water Rosan=ES Reumed 222 2016