_Well Construction - GW1_20230320 (33)

ly LL C NSTRU '..E., 2......_, R19( WI For Interne:Use Only:
I.Wen Ciantratier bformatkin:
iiZed2rLy....±1:j/./.,Ae/ 5,5‘. 44 e.„,, 14.,'W.42/1111 X01016 --
FROM I TO DUCIIIP110:1
Well Counter)?Nemo
ft. ft.
NC Well Commetor Cedificalion Numb Ier .
- .--eliTitit CASING(far mitti-msed**On MK, --1
---...I
Sj.z.sjike_2 4- 1),,ez.;1 ii ri
1(9 PROM TO Duatf/Tittt TOICIKNE$B IfiA
....1 '
Company Nate
2.Well Construction Prat It:12.1.:.:t. ) 12-17-R. iftom TO DIA.tenlit. •Tift Imit„TMAX, . ---"
Lin oil applleable lean oonetruction permits(ie.IJIC,County,State, Varianee,ego) ft. ft.- la.
ft. IL le.
3.Wal Um(dna!wen kage)t
:,:.Iii, Li,e.
Water Supply Welk, El101ft TO ' DIAMETitt " PLOT iliZE TIOCTOIND3 MATIOIVAL
T .
1:3Agricultural 0Municipal/Public Vt. ft.
Offal(Heating/Cooling Supply) 4-Residential Water Supply(single) fi.
Olnduturie/Commorcial
°Residential Water Supply(ilfired) ' cgtown,
Oluipation.. Dwells›100,mGpD iiitOid— 'r'rFft--- 1 --r---------,_ WA itadAL ltateLtarantrer MarBOD at X-M-0-tiler
Non-Water Supply WA: : __....,__........
OMonitain °Recovery IL ft.
_.
ti • .•
it. ft.
ElAqiifer Recharge OGroundwater Rernediation • 1- —......_-
31.
°Aquifer Storage and Recovery °Salinity BattierTO MATERIAL IDIPLACT.KENT MATEO:0
°Aquifer Test OStcrenovater DrainageI
°Experimental Technolov CISubsidence Control ft. IL
°Geothermal(Closed Loop) °Tracer ta.flitILLIZeir• : 4'.,, h.::, •--;.1. ,.T. ‘ ,;-4....,•:i
TO fiaCtliPTION 41er,Ilte4i6s;11,setlivoirit.
1°Geothermal aleatinwtooling Return) ClOther(ex.plain under#21 Remarks 7a1214 ft, ft. •
4.Date Weit(a)Completed:34, *3 Well EDI/.6Z2 3.'lrb
ft. it.
•Al:gd,/ 19,,o4. ,i iv$-c • ft, rt.
1
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? FardlitylOirinier gime .- , ,. :,5:.'.:-'• j 'F'isi*165,(if iiiiilile) ', . •-, A' ,,- 4t-f ,. -T-------
: ,:„.. .:::.-., :, „..•.--'13t: ", • ''' •"v-;L:fi .,':r•-• •: i 4,--'4'-')
' Mislaid XdriaMi,Cliy,44-i.,ip ., . \
zu/
novel Idmtnifiriation No,goo .'i.""-. ,:.-- :..::, !, , ,::: , , ,,, , rib;i::c,";,..,1 ,,..,__ ..
.... •
a•201:3
5h.Latitude and longitude hidegreesholouten'seconds or decimal degrees:
(if well Solt ens Wins it suffloiers) 22.Certificsaan: ' '
dgliffr N .14/1A- W j) .
Sleneure of Certified Wen Coot:soar Da-31111/64te .
6.Its(are)the wen(s):,ipersuanene or °Temporary
•
ay skean thls form I hereby molly that she well(3)was(were)constructed in accordance*vitt
7.Is ells a reps&b an existabg well: °Yes or 4No 1 SA IVCAC 02C.0100 or 15A IVCAC 02C.0200 Well Constraction.Standarde and that a copy
If thia is a repair,fill pla know,well comm.:action information and explain the nature of the 61°Is Y"je'r#?161 gown Provide4?""Or well'' r,: .,.,
min&under 421 roarks sesame or a a the back of this form.
23.She dleirano or additional Wen detain
• &For GeoprobeIDFT or Closed-14:1p Good:10ring Wells having the same You may use the back of this page to provide additional well construction info
construction0,1 G7-1 is needed Indicate TOTAL NUMBER of wells (add'See t--*?in Remarks Box).You may also attach additional pages if necessary.
drilled: 2 .,-4.SUBMiTTAL INSTRUCT
9,Total wen depth below Isand suriace:
For nefaltipla walla lin all cletmAt ifet)ffsre40(eugnple-30200.1:44 24P100) Submit this GW-1 Within 30days of well completion per the following:
llk Stade wafter lewd below top arcades: ( - 5.-- ,,„., 24e. For Aft Wells: Original form to Division of Wawa RVJOLIfeCit artVR),
("4 information Processing Unit,1617 MSC,Raleigh.NC 27699-1617
ffvoro•level it alms why,eqe +" i ., - -,•
11.Borehole diameter: L (b). .2.411.F4anitation Wells;copy tri,Wit,Undenpound-Injection Control-(IUC)•
.;, -. ::- ' '•-,•,, . '' '•••• . PrOirian,1636 MSC,Raleigh,NC 27699.1636
12.Well coastructlon method: t-A, /4--,-•: - - -: ' ''' ''' ' 24:_lroir:Watei Sup*and 0 .ri-L000GeontermalRetura Wells:COPY to the
(Lc' :!E•rotary,b.144.(411?"%tRuilh,etc) com.t,y cay oninental ticalth department of the county Mune installed '
FOXWAltDSDPFL'it WILLS ONLY:
- - • • ,..,
13acineicijoity-' IV i
244...yikpmfleuriirftred .Td,t17: ece Gemi Copy to DWR4•CCPCLIA-;,.
PeriniT &al, 1
13n.:liblintsetten type t Jor--- Amount:Z iiraz-- I
. ' - : ' — ''',- i'
. ,
Perm OW-I Noith Carolina Department of Envisonirstml Quatiry-Division of Water Resoureet 1 Revkied 4:5-2018
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