GW1-2022-09918_Well Construction - GW1_20221031

WELL eONSTRUCTION RE CO, (GW-11 Forery Intal Use Only �-
L Well Contractor Information: -
�riwr� .14.WAT=Z0MW.•.. _J.
WellCanbactor�Nam 1BOM To DSSCMDnON
v{'T T'��� 3DO R 3�IL
R R ( .
NC Well Contractor Catitics imNamyer
�LS.UDTEHCASRIG .mold-ns2d:fello ORLIl�t ra�...::
e\,11,ti.�,t� r �trs S�+/tc FROM To DIADISI&B I TffiC�Vliss MSTriusl,
Co®pwNsme
-- R R
is
E16 INNER'G OR TU=qG Z(osed ldO' `�r''• ,'. n'�''' ::'.;.
2.well Construction Permit#: 3 l)0 3 3 mom I TO DIADISTM TOW MsrlfltIAL
UstaII appbaabk well ooraa�ct[on peradts(Ec WC Cototry.Smut Yar__eye) & R `t h1 y,.ki Gk. J7 t✓G
3.Well Use(cheekwen use): & R im nn__ tt
Water Supply wen.. /17.:to'Cn88N:. -.t cJ7T::I.JY�: hLf 4.t .tom y1F`ci�1�(uri .l.
MOM_ TO - •~DIAMETER SWTSEM •TmcDaw MAY tiAI.
❑Agricultural ❑Municipal/PubiictR - R to.
❑Geothemtal(Heab*Coolmg Supply) @i�dential Water Supply(single) R R is
❑hut„ /Commercial ❑Residential Water Supply(shared)
fllrri ❑Wells>10000001?1) FROM TO MATERIAI. :>sD>placEKWrMelsoDrceMouxr
Noa-Water Supply Well: D R as R
Injeetio ❑Recovery R R
❑AciuiferRecliarge ❑GroundwaterRemediation R R
19 SAND/GRAVBLPACS" f i&lIe '':.T.,rf67:,�y" '. }s :igiz« C'❑Aquifer Storage and Recovery ❑Salinity Barrier . :I+xoM To
MA3RXAL IIIfPLACAIffi?!ME189D'r
❑AquifwTest ❑StotmwaterDnrinage R R
❑Bxperimerrlal Technology ❑Subsidence Control R R
❑Geothtanal(Closed Loop) ❑Tracer =20.DRIILIlVG LOG atteeh`idditioait ah&ti'it"' - ,a
❑Geathennal eatinp/CoolingRetum ❑Other lain under Remadcs FitOM TO DE5CRiF ioN coio ~aovnek .
R R
4.Date weu(s)Completed: /0-/7 Well m 3,1)d33 R ti:
59.Well Lolation: R R
C�.ris Cam_ J� IL
rt r^
R R �- f j �t
Faenl>ty/Qsrmr Name Facility M#(ifsppficable) &
a a�1�1•Au o- 1l;� �"ot� R R
Pkdc l Address,CAS.andZip R R Una
G I G a a>1u zL:
Cyr <J Patel Id on No.(P"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwea Sell,one ladlong is ) ' 22.Certillcation: k
�34 't N 21� µ' SEr �i w f
6.Is(Are)the well(s): Ma irmanent 'or ❑Temporary Signapnc ofCa"edwelitoliftactor Date
Bysfsnbi'f*jb-4 I hdebyo?fWtF=dowell(s)was(mere)eomnracerdataeamdaiwew0h
7.D this a repair to an existing welt:- •QYes or 8No ISANCAC 02C.0100 or 15ANCAC 02C.0200 Wea Cgmcrar m&w dffdr geed doge a Dopy
Ifrldr 4 a }ftU orelnown serll avmnraWaur kybwadan and cTlaat the nawre ofthe of this record hay beers provided m the wrQ a�mer
,P*vfr miler t:21 nv=*seetfon orcn&ebae,Eofd dsf-m 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal we&baying the same You may use the back of this page to provide additional wen constmcdon info
conshuctiM only 1 GW 1 is-needed. Indicate TOTAL NUMBER of veils (add'See over'in Remarks Box}You may also attach additional pages if neoessaty.
drMed
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For nndapk wells brat all deprhr ff�u(ermnpk-3©200'arrd 2(a IM ( �, Submit this GW 1 within 30 days of well completion per the following:
24a. For Ali Wells:
10.
.Static water level below of casing:_-- &2 d I A) lnfomratron Original form to Division of Water Resources (DWR),
maw level is a Bowe Processing Unit 1617 MC,Raleigh,NC 27699-1617
11.Borehole diameter. 24b.For Iniection Wens:Copy to DWR.Undagound injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699436 -
(Le wen construction method:err,) 24c.For Water So 1 and O n-Loo Geothermal Return Welia:Copy to the
method-
(Le-augpy ter.aablq daectpmh,«�)
county enviromn health epartment of the courtly whereinstalled
FOR WATER SUPPLY WELLS ONLY:
24d.For Water wens rosin' over 100 600 GPD:Copy to.DWR,CICPCUA
M Yield(gpm) o1 d Method of test: art/1 p l 11 MSC, C i 611
13b.Disinfection type: T� Amount: fP d Z
Form OW-1 ' North Camlma Departmcra ofEuvuonmental Quality-Division of Wager Resources Revised 6-6-2018