GW1-2023-01855_Well Construction - GW1_20230222

1.Wet/A�Contractor Information:
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Name FROM TO DESCPJFrIOv_ F
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NC ogtractorCertificatioa vI in
Number f15;013TEgCASING foimulda`ediv ORLINER
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CompanyName NN// ll/�.i�+ r.✓� /� ,( D R. Yt� / tn. J
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2.Well Construction permit#: FROM arOMER TMCIaVESs htATIMML
Lfst all appReable svdl eonshucllon permits(Le.WC County,State.Variance eta.) ft: % 1n.
3.Well Use(check well use): ft. it. In.
Water Supply Well: :z17:SCBEErI !!�"sla�`?Ldtirry:
FROM TO 11MM ER I SLOrSIZE I THIC=Ms BTATERML
..Agdcultmal . [314unicipal/Public 0 & ft. in.
_ Geothermal(HeatmplCooling Supply) residential Water Supply(single) ft. f.
IadusttiaUCommercid DResidential WaterSupply(sham
Itri anion FROM TO M&TERML EM UCENEMMMOD&AMOUNT
Non-WaterSupply Well: p f- 12
Monitoring ORecavery ft: IL fi
4jection Well: m D
AquiferRechaige OGroundwaterResnediation
fi19ASANDIGRAVEIrPAGK a'Tieabie ^'..3F�•�;:.w:Y.•in:".;,
AquiferStowgeandRecovery' 13SalinityBanler FROM I TO I MATERIAL EM IACEMENTMEMOD"
_AquiferTest OStomtwaterDrainage R it,
_ Expedmental Technology ElSubsidenceContml ft. R
Geathermai(Closed Loop) OTtacer : 0.11MILUNGLOG sitfaehaddifion`nl3heetsifii- - :+=�:Lf t f7r-+�4:i /`•:
_ Geothennal(Heating/CoolingRetum) Other(explainunder#21Remarks) M� ,L
DES o eator.Lardnem cjc sr tr.
4.Date Well(s)Completed: �Z Well ID# o G✓
Sa.WeItLocation:
Faeility/OvmerName ,.Q �) f� IF
)Lav, 'FFaacOttyIDNOfappItccable) n' r'ti' 4' ': '*-
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Ph i IAddf:m CR andZ ' f f t+ar..�'✓F:s:.n.:.2+9
421..M.E51ARS 7 5rL n�/ /' CP/&County X=cIIdentificationNo.(PIIO
5b.Latitude and longitude In degraw/mlautes/seconds or decimal degrees:
(rfwellMd.one lavloagissumbicat) 22.Certification:
o
6 Is(are)1heweU(S)M<;Mnent or OTemporary SiMatatcofCoffifiedWIContzaawr Date
By darting thts.bmL 1 hereby eerttjy that the svd l(s)ryas(vere)constructed In accordance
%Dthlsavepairtonnexistingwell: 13Yes or•MiNo svlthl5AMCO2CA100orl$AMCOZCWZQOWegCowftctdon&muf *wdthata'
ljfhlsdsarepalrjrlloutknosvnsveileonsauattonl�jararotiorcanderplaMfhenatureoffhe eopYafihlsrecot+dharbeenpmvldedlo�iresveldonvner.
repad•uader#Zl remark section oron thebaekofthrsform.
23.Site diagram or additionalwelldetalls:
8.For Geoprobdi)PT 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.IndicateTOTALNUMBERofwells Construction details.You may also attach,additional`pages ifnecrosary.
drilled: SUBMITTALINSTRUCfIONS
9.Total well depth below land surface: dP 00 24a.For All Wells Submit this form within 30 days of completion of well
For multlplewdlsllstall depthstfit,Bennt(ezample-3@209 2Qo-and 100) constructiontmitefollowing:
10.Staticw Paterlevelbelowta efeasin - )h r ft. i
lfwaterlevel&abaveearin&use" " g- ( ) Division
l 617 Mail Service Center, eight NC27699-1Piro 617 nit,
ll.Borehole diameter: 21-pTunzp
24b.For Infection Wells: In addition to sending the fora to the address in 24alz.Well construction method- �f above,also submit one copy of this farut within 30 days of compleffon'of well
constmctiontothefoilowing: I i
(sa auger.-My.table,directpu9b,etc.)
Division of Water Resources,Uadeigt:oundlnjecdon ControlProgtam,
FOR WATER SUPPLY WELLS ONLY: 1636MASerdce Canter,Raleiglt,NC27699-1636
13a.Meld(gpm) U ® thud of test �i ` l 24c.For Water SuoDIv&Infection Wells: In addition to sending the form to
the addcess(es)above,also submit oae'eopy of this form wItbin 30 days of
13LDisintiection type: _ Amount: completion of'well constmction to the county hearth.department of the county
whereconstructed. I 1
FormGW-1 North CamUnaDepastmeatoMvim=cnulQuatify-Divistonof WaterR==cs Revtsed222.2016