GW1-2023-02726_Well Construction - GW1_20230411

WCLL CONSTRUCTION RL� .�D GW! For Internal UseOn!
I,JX.dlC ntractorinform Qon:
U C!�'!�//41(�d� 14.WATERZONES s
FROM TO DESCRI1710N
Wc11 CommetorNmna n R, ,0 ft.
n—Q�.�f .P-t / R. 1f fL /
NCWeHCarumetorCllertiilioationNuniber 15.OUTERCASINC formuldcas Yells ORLiNER Ifs ((cable and ��'� 1 t F�toMr To D1A-rE ER TruclaEss. DurERr,\t
Z.t m R Ia. .D
Company Name + �n/ �^/_ 16.1NNER CASING ORTUBING 1 ealhervial ctmd•ioa
2.Neil Construction Permlt#: joa)_, �+•6ws r /�0�`�+ FRO?I I TO I DIAMETER I THIC1:.NESS "IATERML'
List all applicable coattruction petmitsV.e.U1C Ca:rr.0:Satre-Vatiaare.eta)
• iL fL la-
3.Well Use(check well use):
IT.SCREEN .�c�'•'- -
Water Supply Well: FROM TO D14\IEr•ER I SLOTSIZE I THICKNESS SLATEAiAL
Agricultural ©Munieipaf/Public 1. 0 R. lo. � h� Z!J U
Geothennot(Heafng/Coof(ng Supply) Residential Water Supply(single) R,I In.
itidushiaUCommtxcial Rrsidcntial•WalcrSupply(shared) IS6GROUC ,-
Irri ti0a FROM TO MATERIAL EDIPLACEMFNT ETROD&A 1041i`r'
t1. -
-- —
Monitoring []Recovery
Injection WeW ft. R.
Aquifer Recharge ❑GroundwaterRemediation 19.SANDIGRAVELPACKtifa Ilnahle • •'_ '" 1-.7 •••;7- ••• "
AquiferSttlmge.andRecovery []Salinity Barrier FROM I To MATERIAL EDtp[Ac£at17+Tn+Enton
AquiferTtst QStot, \vaterDsairuga 0 ft• e ft.
tt
ErperimentalTeahnology []SubsidenceConuol ft. fL
Geothermal(Closed Loop) [:3Tr•cer 20.DRILLING LOG(attach addltloasl sheets ff necessary)
FF MII TO DF:<CRti'r10M 1ealo.EaMaess toiVroekh e. minslaaete.
Geothermal(HeatingiCooling Return) Other(explain IMCIV#2l ROWes) ft tL
A.Date Will(s)Completed:*a-1Or��-•Well 1D#
• Sa:(Yell Location: - - r^ ..,,. � •_--•
1 (- APR ,-, 1 7
coil IDII ifn lleabla n• It.
Faclii 0waarNan+e Y ( p )
�lUll n• -ft.
P lea 11 city,and Zip
J -21.111LEMAR1CS ,
Coyniy + Parcel Identification Naa,•(FIN)
5b.Latltudeand longitude in degreesfnliruteskeeaads or decimal degrees:
Cipfall field,one latllong a sufficient) .Cerlific I
J L t �it i'l �D t �•�tt W .i WO'Cenitied\ it retractor; to
6.Is(Are)the wellookermament or Temporary• .
11��..��,, s(galag this form,I hereby cen16'that
the mil(j)Sim(urtr)coattruaed Lt aecatdanre
7.Is this a repair to an existing well. �Ycs or Na ufrh 13ui A'C C 02CJ7100 or!Sd A'C.IC 02C.0:ti01Pef:Coratnr<tioa Stardards'and ch4fa
If this it a repair,jlll otrt lstan,t hell constructive+lajormadon n wrplata the nature of the roW'oJdrlr rttortl has beets ptot'ided to die ueU'qunrr.
repair under i111 remar tr seuimi or on the back-Of thil ornt• 23.Site diagram or additional well detals:
You mayuse the back of this page to provide additional well site details or well
&.For CcoprobclDP1'or Closed-Loop Geothermal Welishalring the same
eoastrac ldn,only I G%V-1 is needed. indicate TOTAL NUMBER ofwells
construction details.You may also attach additional pages if necessary.
drilled SUBMiTTAi.iNSTRUCTION3
9.Total well depth below land surface: 1 (2 130 (ft.) 24a.For All Wcllse Submit this form within 30 days of completion of wen
For•multiple us1h list all depdrr illditlereaI(eeample-3(g 00•turd 1Q/00') COmtnrotior 4o the following:
10.Statiewater level below top of casing: (It.)• illvislon of Water Resources,Information Processing Ualt,
ljsmter 1t+:1lsabore crislOZ.use'U=' -1617 hull Servicetenter,Raleigh,NC 27699.1617 ,
11.Borehole dblmeter: l /Z (in) 24b.ForInjection Veils:-In addition to sending the form to the address in 24a
above,also submit one copy of this fom+t within 30 days of completion of well
12.Well'constructlon methods t " ' construction to turn foilowirrg: i
(Laau�eyrotary.eabiGdt,eccpusl�ae) _. ;_ ...
Division of Water-Resource-4 Underground lnjcetion Central Program,
FOR WATERSUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636 ,
13n.Yield(gpm) / Method of test: 24c.For Water StmDiv&fniceRO11 WcBss in addition to sending the form•to
the address mses)above, also submit one copy of this to •within 30 days of
dab.Disinfection type: Amount•. U n Z completion of well construction to the county health department of the county
where constructed.
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Fom1GW1 Nord+CamlinaDep+amentOfEnvironmantalQuaiity-DivislonofWoterResow�es -