GW1-2022-00274_Well Construction - GW1_20221222

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1.Well--Contractor Info�r/mati/o�n:
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t.i9�n L/ /Ju y/7�st rli�l l :XVATERZOXES >Yiji•:$.= •,ph L7• a:'
WellContractorName FROM TO I DESCRIMOI
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NC We1lCo IL -v kntractarCerttfiratioaNumber s'1S:OUTER:CASING fo"rm°Iti ed.wblLi OR_ R
--�� FROM TO D
ft. IAMETER I THIC[aVESS MATERIAL
G�.,� �� fa I ins
Companyllame VC,
t / 446:•I1iVER'CASING ORTiiBING:'eufir"eiiurel eldYed-loo 1?:;3?i <; :z,'ss„,c.•s:;:
2.Well Construction Permit#: _ ZQ7 FROM TO DIAMCFER I THICKNESS t hIATERIALr
List all applicable well construction permits(Le. C,County.State Variance eta) tt. ft. In.
3.Well Use(check well use): ft.
Water Supply Well: c17.•SCREE N33c` 2,'•'::e%a ::5.;%'t<tbi?i�::;i.:�i?:9rs: s?:.Ci,� ;_;,s�i_-< SSi:;z:�:•s
FROM TO ^ :I DIAMETER SLOTSIZE THICKNESS MATERIAL
..Agricultural 13Municipalftblic () ft. fL in.
(Heating/Cooling Supply) 131tesgential Water Supply(single) ft R in.
lndustriaVCommercial esidendal Water Supply(shared) _
YI&'GROUT:'- 'L',:z+.•:-'y?*'e'k:'fi'.;;.4:Kt'.' 's.'.v.�Yy.., � !L 3:>SS :�ti�t:•%'•i:Y:vl.::�%.`:•'<
kri ation FROM TO MATERIAL EMPLACEMENTMEMOD&AMOUNT
Non-Water Supply Well: a fa 00,
Monitoring `Recovery n ft
Injection Well:
.
ti iG ;
AquiferRecharge OGroundwaterRemediatiom r•.r:...:••r::<::.; .-.
1,19:•SAND/GRAVECPACIC fib livable :;<:.,.,...,:.c.....:.., :•?,::.:5a+:x,: :`:.:
Aquifer Storage and Recovery OSalinityBanier FROM I TO I MATERIAL I EMPLACE6rENTMEMOD
AquiferTest 13StormwaterDtainage ft. R
Experimental Technology Subsidence Control ft. ffi
Geothermal(Closed Loop). J3Tracer ''120......LING LOG eita2baddifiSnaIabeetiifiiiFes �r;iita l �:_'is-'ice
FROM TO DESCR>PTION eolar.Iau+rnesr.snrVmek y sa.etel
Geothermal(Heating/Cooling Retum) Other(explain under#21 Remarks) !t:
4.Date Wel(s)Completed:,f dl- ZZ'•� waunw / tt.
So.WellLocatiio�n�:2 ) / 7 fa 2L �
Fficillty/Ow°erTN Facility ID#(ifappililcable) fA % _
�. r r, cs,S/►/n Z7�w �wl „p,-7/cyi ,/�G ft. tt. `'4�6: Lz os't )
Phys=IAddress,City,andZip 19a3Z iG et.
_/b�•��O YI `ELSREMARKS`: �'�7.f"•'_=�.'��.r�' ;+�e.� :.1r';;r,;:
County ParcelId=d ficadonNo.(PIN)
Sb.Latitude and longitude is degrees/minutes/seconds or decimal degrees:
(ifwcU field,one latflong is sufficient)
�, �,, / r 22.Certification:
r 9 S 7
(/ I, - 2 2-
6.Is(are)thewefi(s) e g�raeOFceed Wellconhactorrmanent or Temporary Date
By stgning this form.I hereby caWfy that the rvey(s)was(were)constructed N accordance
7.IS this a repair to an existing well. r3Yes or ff3wi­ with 15ANGIC 02C.01W Or 15ANCAq dC.0200 Weil Constraaion Srandards and that a
Ifthls Is a repair,fill out Imowa tveU construction Wannation and explain the nature ofthe eomethlvrecotdhas beenprovldedto the ivell mvner.
repair under#21 rmnarfa section or on the backofthtsform. 23.Site diagram Or additional well details:
8.For Geoprobe/DPT 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 1 GW-1 is needed. Indicate TOTALNUMBER ofwells construction details. You may also attach additional pages if necessary.
drilled; SUBMITTAL INSTRUCTIONS
9.TOtalwell depth belowlandsurface: �2 0� 00 24n,For All Wens: Submit this form within 30 days of completion of well
FormufOpfe weUsllStaff deptfulfdf�aent(example-3Q200'andlQl001 construction to the following: I;•
10.Static water level below top of casing: S O (ft.) Division of Water Resources,Information Processing Unit,
lfwater level&above easln&use+" 1617 Wail Service Cint r,Raleipiy NC 276991617
11.Borehole diameter: (in.) 24b.For Infection Wells: ht addition to sending the form to the address in 24a
11 4 above,also submit one copy of this form within 30 days of completfowof well
(ic Well construction method: 1 a'7 r /_ _.auger,rotary.cable.direetpusb,eta construction to the following:) •
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Ralefgb,NC 276994636
13a.Yield(gpm) U Method of test: 24a For Water Su°niv&Infectilon1 Wells: In addition to sending the form to
the address(es) above, also submit one-copy of this form within 30 days of
13b.Dislu ection type: Y Amount: oZ O -4 r completion of'welt construction to the county health.department of the county
where constructed. I.
I •
Form OW-1 North Carolina DepartmentofEnvimmnentalQuality-Division of WaterResomces, Revtsed2 22 2016