GW1-2023-02523_Well Construction - GW1_20230406

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1.Well contractor Information f� _
rsoas xo DESCRIPTION i
Well contractorNaz - —� - —
NC Well comclor QettifcatioaNalmbct ]5#1t33ER('.ASDXG Turiaalti raud'i+e2As iDR:•Y B Ufa 'iseble
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'4YAterAupply Well; To_. _ n - srAnSrZE TOXIMESS InTEtuat.Agaculttual�oihermal(H.ating/Cooling Supply) Rosid+�lU�T owSupply(ti>i id)�ResidentialWaterSu l shatvd _Noni vaterSupply VCR- iz
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AquiferRecharae Dram md"ater'Rammation
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x fi nel Aquifer Storage and Rmovc y r3SalinityBarrier _� _ FAIPI ACENMir,IEMCD
A uiferTestFeximentalTechnologyCmthertrtal(Closed Loop) TracsP sGadEut:otiat el�ssts fsifeasa
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G�Dtltermal lieati� C'ooliDe Retum DWar(... widi r#21 Rea>>
a.Date Wel(s)Completed: Av u I — - _ s - O ( ^ - C/
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tia.Well Location; S eJ ti Op tt Ct /Gt' rl, 'Z
Facility/ov;cerNamc Fac,lity llh(ifapphcablc)
pl�sieal Address,city,and
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County parcel Ideotibearion�To.(pig _ - _ � J _._ ..
tib.Latitude and longitude3u degTwsindriuteslstxonds or decmml degmes; _
(ifavc115eld,one latllottgisMdEdem) / -7 /�,� zzcc ttio IftiG;.3?s ?C:•..r t„
Si��led Wei!Contractor Date
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6,rs(n)the WCH(s) Permtnent oz Temlwt try
.y.v,q"jltg this fgrna 1 hereby oerlffy that file x=edd(sJ fiefs(Hare)consfnrcled in accordance
.is thas A mpaii to AliC tlJ well: ®Ye5 Or No wttl+15A NCAC 02C.0100 or 15A MIC 02C.020o well Conatrnctron Stwrdards and that a
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7 this is a repair,fill ant U mnsrlucrlon i,rfonnationand 4xplGdn rl,e nature vftha copy of this record luubeen yravided to the well mmen
repair totder n21 renfarJssection or ou the back ofthisforn" 23:Sitc diaaramoradditional wdl dctalls:
8.For Geoprobe/1APT or Closed-Loop Geotherritul ll'elts havilIg the same You ray use the b.Y of this pang to prowdit additional tivsll site details or wall
censkt C ion,only 1 OW-1 is needed. Indicate TOTALlti`[WER of�sells
construction dettsils You may also attach additional pages ifnecessary:
drilled: sI1BiVIITTAt IIV TRL crloNs
9.Total well depth below land surface: 7,o (t) 24a. For 0'aft.- Submit this form vdtbin 30 days of completion of wall
Formultlple wells list all depths ifLUfferent(e�niple-3(a�)tVimtMI cciltstnrtriio7ttotlle f911Stiving:
10,Static water level below top of casing: -_ - 7 OQ Di..islon of Water Resourm,Irtfoa�ation Processing Unit,
f,ivatcrlevel is abmv cadng.use"+/"� 1617141ai1 Service Cotter,PAdg%NC 27699-1617
11.Borehole diarrrctcr.�!'� (�) 24b.9 r Inieetian Weus: In addition to 5%idioa the form to the address in 24a
above,also submit one copy of dtis form Ivitbin 30 days of completion of well
12,Wen consttvrction method: consttttclion to ate following:
(i.a,auger,rotary,cable,direct push,ctc.) ap�
Ditisio>tl of 1�'Ater Resources,tlndexgn►tmd lgjestiort Control Pro
FOR WATER SUPL,Y%I%LLS ONLY: — 1636 Nun ScrvIce Center,Raldgh,NC 27699-1636
13� sold ltietl►od of test° _ 24c for S4'ater Stmrth&InieMion R`elk: In addition to sending 01e form to
(t ►u') © the address(es)above,also submit;one copy of this form-within 30 days of
/_!�l,n r. completion of t+�ll consuuattoa to the county health department of the cottttt}
�3b Itldnfcstion type; �� — aitcra constrractod,
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