GW1-2022-00287_Well Construction - GW1_20221222

_ "•"�.....vvasviawviivi�iWa..V1W w'/��11 ror internal useunly:
1.Well gntractor Information:
14.!WATERZONF3: -:'r -;'ri. _% "•t: ti't. i:j;' �•.
Well Contractor ame FROM TO DESCRIPTION
`� tt. tt. p
t�/ ft. R.
NC Well Contractor CettificatioaNumber -A OUTER:CASING Wi iiiniti iSdSveUJ ORZlNER fs"'lieablb �3:;:::',:::,-�i•;
FROM To DPAMErER I11 THICPINESs n TERMJ6
CompanyName ®ft. it. to.I ��
,.1&-MNER'CASINGORTUB G: eotirEiiiiaielmed-l6o ? :?`, +r.'c r0
2.Well Construction Permit#: FROM - TO DIAME[ER i THICKNESS • hiATER1AL
List all a.ppricable ivdl canstrucBan permf&(Le.UIC County•Stag Parlance eta) & in•
3.Well Use(check well use): fL it. fin•
Water Supply Well:3. 17.'SCREEN?;ti cy ",'•+:iisc'.:5.:i!<ikaiE 'r:�.:3�i9r ;1;jsS•s ;i e: a%ttr%.S5
FROM TO BLOWER SLOTSIZE THICKNESSao MA
Agricultural �}Mttnicipal/Public tt & in,
. Geothermal(Heating/COoling Supply) Residential Water Supply(single) fL ft,
Industrial/Commercial DResidential Water Supply(shared) _
.•`JIBGROt1'rl.'r 1£:,+.r",{' n.e::i?i�.•.iin^'i'e: '. i'i'e'!'« �;t4:•� f.8•:::'-;iiC:'!� ?+Y it =.::�.`_
'Ibrigation. FROM TO MATERIAL i f• EMPLACEME aMEPHOD&AMOUNT
No Water Supply Well: ft- ft.
Onitoring Recovery ft. ft.
Injection Well: iG
AquiferRecharge oGroundwater Remediation
Aquifer Storage and Recovery 39'•SAND/GRAVEIrPACfSa'•-lieebiE �iii-�?;e'+'i',,di:':: SiE�'e::�;s.�:;-`..:=�>+:•�; v;T.••.
�SalinityBarrier FROM To MATEEWL. + • LMP yCEBHEWMEMOD
__ AquiferTest 13StomrwaterDrainage ft t�
Experimental Technology OSubsidence Control & ft.
Geothermal(Closed Loop). 13Tracer 20?DRILLINGI OG dttacbaddPNSnai'ah6eti ifiiiiensa" 'ter:;t_:;sJs
-�.
Geothermal FROM TO DFS ON a rer haeraeMsarPaxk
(Heating/Ccoling Return) Outer(explain under#21 Remarks) ft fe
AP
4.Date Wells)Completed: Well ID# n
5a. ellLocca�atiion- &
Fbc 'ty/OwnerNa e - _ V -FacttityID#(ifopplfcable) ft. ft. �� •-,r R-a ��-L-
tt. fL E r
hysi/c�aIAptd ,Cr�t7Vr and Z' R• fL
?2L%PMIARKSCi f'ti=".. F cA.i,r•it
County .. .Parcel IdenN6cationNo.(PW Dil:tQu:}L
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(ifwell field,one latAong is sufficient) 22.COW
ertifi tion:
3�°.�a3aaa N (f Dd dpI Y 1 W
6.Is(are)tbewel1(s) r 1nent or OTemporary sipat=ofcadq6dweliconu5aw Date
��s By sfgntng this form.I hereby een*that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or [gf o Idth 15A=C 0IC.0100 or 15ANCRC 02C.0200 Weil Conrrrudian Standards and that a
Ifthls is a repair,0 out lnown'veil construction btformation and explain the nature ofthe copy ofth/srecorihas beenproOded to theavell owner.
repair under#21 remarks section or on the back ofthisform 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"page to:provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER ofwells construction details.You may also attach additional pages if necessary.
drilled' ✓ SUBMITPAL INSTRUCTIONS
9.Total well depth below land surface: (ft•) Tifa For All Wells: Submit this ftinn within 30 days of completion of well
Far ma/tlpiewells list all depths lfdffl1--t(example-3®200'and2@100? construction tothefollowing:
10.Static water level below to L
p of casing: (ft) Division of Water Resources,,Informatioa Processing Uffit,
lfwater level Is above caring.we.+' .3617 Mail Service Center,Raleigh,NC 276991617
11.Borehole diameter: (in) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion'of well
12.Well construction method: ,� construction to the following.
(ie.auger,rotary,eabie,directpvsb,eta) .
Division of Water Resources,Underground Injection CoatrolProgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Matt Service Center,Raleigh,NC 276994636
13a.Yield(gpm) v Method of test: 24c.For Water Supply&Infection,Wells In addition to sending the fora to
the address(es) above, also submit one'copy of this fomt within 30 days of
13b.Disinfection type: 44 Amount: completion of well construction to the;county health department of the county
where constructed.
FamGW--1 North CamlinaDepartmentofEavironmentalQuality-Division ofWaterRcsomces �, Rev1sed2-222016
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