GW1--04858_Well Construction - GW1_20230728

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• WellConaattnrName MUM TO DESCRIPTION
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NC Well Coatmc or Cectifcetlon Number
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2.Well Construction Permit#: (/ • FROM TO orabrcre(t •TWCra arATearu
List al applicable well coimnicdonpennhs(t e.iRC.Colony,Stare,Variance,aicJ- R erop—tr. In.
3.Well Use(check well use): R, n M.
Water Sapply Well: �1ti8t;REEN9`, x=,. ='= -,:.-:::• ::•---
FROM TO DIAMETER SLOT SUE TLIERNEE MATERIAL
OAgricuIt ual QMunicipal/Public O R. tr. io, a"
MGeM6n,mal(Nenting/Cooling Supply) deatial Water Supply(single) R. m in. .
r}hrduahial/Cammereial _ ❑Residentlal Water Supply(shared)
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ge FROM TO MATERIAL =PLACEMEN[METHOD&AAIOUNr
iYoa•Water Supply Well: © R f,),-2 re% E` �iry tit.
�1Monitorin Recov� N : �' `�
Injection Well: R• R• __
• gAquiferRechargo [�GmundwaterRemediattion fr., -
Aquifer$ and3R:SANDIGitivinfiPAerti MATERIAL ; • '•'z NT
Skimp Recovery OSalini(yBarrier FROM TO EMPLACEMENT METHOD
AquiferTest 4OStarmwater Drainage ft. n
Experimental Technology Subsidence Control tt. R.
Geothermal(ClosedLaop),- Dlraeer '10_ARTtIINGI'bG(liraiiiiidhiotuirelieetriRiticBiiiiifI ....
h Geothermal(Heating/Caoli4Return) JOther(explain under 021Remarks) 1mm co DfscalvrtOv(nlar,tu,aanr,�Ivmctct�.j,R.msQe,elra
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d.Date Well(s)Completed; ,0)2 Well IDS.. /'v fc
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5a Well Locations It r/'G�.ft. "47. P//��
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FacilitylOwaecMame Peeks,IDti(if ippticnbln) fa rt.
(P/h/y/s'kdidi Addtass,City,add Tip •' (/' /' 1////���� �v':��-{ �rL�(yy,� rt. 1- ...L,I:
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County Peieal tdemifieetida No.(PIN) `JUL- 2 tI l J
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees: >3a:.- : h,••.: • __ ,,...x
Orwell field.one tet/leng is sufficient) a
22.Certification: �,tj g�" �• DaeCdr'J::►a •
S. dt)2i /7 N /9/2X1 ' W &®.fit- lI dAvi d/ ?
6.Is(are)theweli(s) Permanent or )Teroporacy 9it��or�emfied Well Conaacror Date
By siring du:forni.I hereby carafe thin the tra/I(s)Ira!(Isere)constructed ill accordoace
a 7.Is ibis a repair to an existing mil: Oyes or ONo with 15d NC4C 02C.0100 or list NCAC 02C.0200 Well Coannnuion Swadox(r and that a
pis is a repair,JIB as/nowu wdi conatrucriar hJarmaiion and replan the netting,the copy ofrhis teeohf his beenprotgded he the well orlett
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repair underlt2l remark section 01'on the back of this-form.
23_Site diagram or additional well details:
• 8.For Geoprobe/DPT or Closed•Loop Geothermal Wells having the same You may use the back of this page to provide additional wrll site details or well
construction,only 1 GW 1 is needed. Indicate TOTeU.NUMBER of antis construction details. You may also attach additional pages if necessary,
drilled:
_ SUBMITTAiiNSTRUCTIQf •
9.Total well depth below land surface: (n•) 24a. For MI Wells: Submit this form within 30 days of completion of well
For mnlapk vets listal/depthsite&fferciu(esmaple.30200•and VVIGO') constriction to the following:
10.Static water lave[below top of casing: ? (ft.) Division of Water Resources.Information Processing Unit
If weir lag lr above caring we+" 1617 Mail Service Center,Raleigh,NC 27699-1617 r
11,Borehole diameter. 42 'kJ (In,)
24b.For inlecllon(Yells: In addition to sending the Turn ro the address in 24a
12.Well construction method: g04-r Y( - above,also submit one copy of this form within 30 days of completion of well
(ia auger,rotary.cable,dual pulls,elo.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division at Water Resources,Underground Injection Control Program.
1636 Mail Service Center,Raleigh,NC 276991636
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130.Yield UPI*) do Method of test: It-'4llr Zde,y For Water Swink,&Infection Wells: In addition to sending the form to
• l Li the address(es)above, also submit one copy of this Tams within 30 days of
• type:13b.Disinfection / rf Amount:, C-6- completion of wall construction to tho county health depernnent of the county
J where constructed.
FORAGW-1 North CamilaDepvtdieat afFavima secret Quality-Division of Water Resources Revised 2-22 2016'