GW1-2022-00289_Well Construction - GW1_20221222

1.Well C tractor Info ation .5,p ps,:�-p
.1 ZONES'.%.'O.,P-N, 4,
ZZ:mLa N_
WeltContractorNime FROM TO t DESCRIPrIIN 1
,242 it.
ft. V
NC Well Contractor Certification Number cri V15.101JUW-CASING(fadf a *Hh)
a 4de FROM TO DMMS7M1 IRM-M2 ZERIAL I
61W. P�
CompanyName 0 R. /0 ft- 2 110-11
16:1KNEIXCASING OR.-TUBING.'fireftififfil W&id-I&W
2.Well Construction Permit*:— FROM -I TO I IDLAbWEEL 1, 11 TMCKNESS I MATERIAL
List all appricabletvdicans&uctfon permits(re-WC.County,State,Variance.etc) ft, ft.
3.Well Use(check well use): ft, m
Water Supply Well:
R,
FROM TO DIAMETER SLCYrsME 1 TMCKNESS MATERIAL
I
DAgricultural OMunicipallPublio /0 ft. L 229 1
_1Geothermal(Heating/Cooling Supply) DResidential Water Supply(single)
a ft In.
Industrial/Commercial DkesidenfialWater Supply(shared) ga:
'11ndRation FROM I TO MATEMAL EWLACEM2=MEM0D&AM0UKr•
N WaterSupply Well: -9 Irt, ft
Injection
Recovery ft ft
"Nection Well: ft ft
3AquiferRecharge 013roundwaterRemedlation IL19.-,SANDIGRAVEL-PACIC-(ifiibbUabI.
Aquifer Storage and Recovery r3SalinityBarrier FROM ro I MATE AL
I MA—cEmENTMEMOD
3- AquiferTest OStormwaterDrainage oqp it ft
IExperimental Technology 13Subsidence Control ft
30c9thermal(Closed Loop) nTracer *i20MRELL1NG L(OMMG
nGeothermal(Heating/Cooling Retum) n0ther(explainunderf21 Remadd) FROM To IDESCREMON(caTor.bnr&=XoHrncictYmeraln3iDC,etr.I ft. fL
4.Date Well(s)Completed: WeIll][119- & &
Sa.Well Location: &
ft ft.
rg� fffL — r"�'r-IA 4­V­.
RoijitylOwnerfmame asft M#(trappucable) ft ft. r
ft. ft
PhysicalAddress, anandZip V & ft BEE
s2l.TREBL4PSS*.-.�!;',,,'.4�';l- -ga
0G
County Par el Iden0cationNo.(PIN) ENJUI 111L
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(irweu Eel one lat/10 is sufficient) 22.Certification:
anal N
6.Is(are)thewell(s)Ver=nent or j3Temporary Date
By signing thisforn I hereby certify that the lvdl($)$vas(were)constructed In accordance
7.Is this a repair to an existing well: E3yes or 0mr- irith 15A NCAC 02C.0100 or ISA=C 02C.0200 Well Construction 21tanifards and that a
Afthis(S a repair.A out Anol M Well construction infannatian and arplain the nature ofthe copy oftfits reconthas been pmylkledto the i veil oj men.
repair under 021 rentarks section or an the back ofthfsform
23.Site diagram or additionalwell,details:
8.For Geoprobe/DPr or Closeid-Loop Geothermal Wells having the same You may use the back of"page to provide additional well site details or well
construction,only I OW-1 is needed.Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages if necessary.
drilled- 1, 1
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: d9 —00 24a.For All Wells Submit this fulm within.30 days of completion of well
Formall4yie welirlirtaildepths trdffeirent(-arpfi-3@200'and2@1179) F ;
construction to the following:
10.Static water level below top of casing: (ft) Division ofWaterResourcisi Information Processing Unit,
lfwarer level fs above casing.use"+7 1617 Mail Sn-Ace Center,Rafe!Ah,NC276991617
1I.Borehole.diameter: 246.For Infection Wells: kL 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: A'MA-q- construction to the following:
(ic.aug-.zatuy.cabIc6 divay-b.etc.) I I-
Division ofWaterResources,Underground Injection ControlProgmm,
FOR WATER SUPPLY WELLS ONLY 1636 Mail Service C6ierRale1gb,NC 276994636
13a.Yield(gpm) Method of test: 24c.For Water SurDiv Be IntectiI nlWells: In addition to sending the form to
the address(es) above, also submit no*copy of ft form within 30 days of
13b.Disinfection type: completion of'well construction to county health department of the county
ja- Amount. where constructed.
Form.GW-I North Carolina Department ofEaviromentat Quality-Division of Water Resmucesi Raybed2222016