GW1--03991_Well Construction - GW1_20230612

ALL ��I�� �7c ig� 20 (e3 -�S For L '�,. 1y� .
1.wen qbntr4etor Information:
" I FROM i TO i Dr.SC'R?PTiG!
�4'eliCoatractoriv�me j , `t. l��3 ft• � /%f�! i
p i I C
!
NC Well Contractor Ccrtitication Numbei
Miler ilVeil ®riiiif^ig FRO.-NI I TO D?ANtFTR i T3TC+�FSS ATATFRTAi. 1'
ft. ft. in. Sid 2 r; ?vC
Company Name rl 1 s6:TN ER C.AS2"NG OR k a]NG eatit'e:--, rc16S&,loort
2.Well Construction Permit-: �dlrG���LV���•7 FROM TO l ..i mu: `R ! c I.c k�Fss I MATERIAL
Al.
List all applicable-4-alZ consomctlon penrits(i e.IiIC.County,State.Variance,etc..) ft• f:. m.
in.
3.Well Use(check well use): I.
Water Supply Well: l FRGYI TG I D.n�,?TEZ i K.O.SIc I T z.Cn\ SS OT:1TEr2IAL
OAg icultunl ❑�4mticipal/Public R. I ft. to
❑Geothermal(Heating/Cooling Supply) .esidential Water Supoiv(single) I ft. 1 it- I in. j
OIndustrial/Commercisl OResidectial Wat-r Supply(shared)
❑irr nation ❑Wells> 100,000 GPD FROM I TO Me,TF.RTAL I F.dt?t ACF.XTSR T F.M Or)S AdrJ'u"�T
Non-Y.ater Supply Well: C'i j •�} I Y�!' lG 1 f y�c.ti 1 I
❑Monitoring ❑Recovciv 7 t't. I n} ft. r 1 ✓'! ?. r
Injection Well; i ft• f°
OAduifer Recharge ❑Groundwater Remeciiation
?9. tikv _
OAauifcr Storage and Recovery OSalirity Barrier sRvvt Tv I Yi�TERi+L ! sa,?„aC vT nt .avD
OAquifer Test O Stormwater Drainage I ft.
I
❑Experimental TechnologyOSubsidence Control
I ft.
OGeothermaI(Closed Loop) ❑Tracei !'; '+� fit"L��:t=tt^c 'a3di aariLees f recess.al
-Rom -O I a=SCRt?T?OX lepton,e..:dacsa so.'Jrocn itoa_..ra a;ze,etc.!
OGeothermal(HeatinglCooling Return) ❑Ocher(explain under Remarks) i
4.Date Well(s)Completed: - 7-:-.Z— Well mi; �e 1i f" f f• .(f'J n= Yf3C!v c cf 41
5a.Well Location: ?;
ba, no, CL 162- �zt &rz:A
DO
f
Facility/O/ . rName { FcilityID=(i:applic2blc) >z1 i�s_<� .` �.�8/i� /.11'n-ni;t•
��l �f,�''l��U 0���:i7 !i.G'/ •FJ�(�i��!11�.a.?r� I ft. I ~- � �.5 S�..�'4"v.a d•�r� I
P ysic::l;Address,City,and Zip ft. I •t L L_ �V I tj
i v 1 J
County Parcel ldcntification No.(PIN)
° lfltCifl4»:{v 1 7fC '8Iryi�f�n2-
• Sb.Latitude and loan trade is Ica eeslminutes/seconds or cieePmai decrees:
(ifwcll field,one latflong/iis/suufr,cicm) 22 Ce t _•ficatla .JJJJ r'
6._s(are)the weli(s):.Of rmanent or �Tempor arti Si�atu a of Certified 41 e f.^.oatr2ctor Datc
,� ��sigrr�p f;�ia Torn:,l int;r nr rrrritj;ru;rir::rllrry+vas hrr•;:}:v,,rstrtrcrczi ir.accvrd mca,
7.Is this a repair to an eysting welt: __ O'_'es cr ,�;<p 1:. NC4C. _C.010",rr i 3.4 A'C.i C C?C.1,200/.':11 conr;r,:ciiar.Standardr and that a cr.;.:•
if this Lc a repdir,Jill orlt kro)-:a well cotstnccliort h fontrat ar anal explain the rantra of•thc of this re.n,d haz ircen amrided to the
repair tntder',31 remarks section or or the back orthis•%rm.
23-Site de2g:aw.or additionti tn'231,de.ails:
8.For Geoprobe/DPT or Closed-Loop Geothermal WeEis having the same You may use the back of this page-to provide additional well construction info
construction,only I Giro-1 is needed. indicate TOTAL NUMBER of wells (add'See Ovr,'in Remarks Box):You may also attach zdditidnzl pages if necessary.
drilled: 24.SUB?U T T°_LIST_cUC r j0N-S
a
.Total well depth below lard surface:
p rP 1 >T G �n c:rci_(at•(fff') ( Submit Litt :s^ '-:v::tain fi days o:well conSDietion per the folloning:
For multiple wells list all d rhv i di ererl(example-3 ai1 i y
24a. .a> A. tiJeiis: Original.for in to Division of Wate: Resources (DWR).
10.Static water level melon top of easing: _J z.J <—> 1n_ormatia.-,Processing Unit,1617 MSC.Raleigh.NC 27699-1 6 1 7
q'samr lovol is nbovn cc^ing....re —�
11.Boreholed-aameter• l% 24b• For enicetion'WeNs:Copy to D1WR.'Undergroufiid Injection Control(RUC,
(>�) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
J 24c.i'or t2:er SuDris au ODe Lod E,eeti ermai tarn rzJelis:Copy to
n,e
(i:c.auger,roary,cable,direct ash,cto.> f county ervvcnmentai heap:,deram'e. of the count-,--where insia(led
FOR WATER SUPPLY WELLS ONLY: 24d.For Water ab elEs iorodacin3 over I00,000 GPD:Coov to DWR,CCPCL'=_
13a-Yield(gpm) 7✓ Method of less p�ntt Ptog am;1611 v1SC,Ralcis>h,\C 27699-161 1
13b.Disinfection type: ri All amount:
•
Form G W-1 North Carolina Department of Ezvironrnen'yl Quality-Division ofVVv_,r Resources Revised 6-6-20'.F.