GW1--05762_Well Construction - GW1_20240926

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, ,: ,t ',WO`' INRe idennal Water Supply(single) _.._- ft , ft. in,
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01^tiur,'a I<4'0,111144'1i.411 ORe.askntlal Vr Mot Sullins.(shared) IS.GROUT - ----
riL-ngat,on FROM TO r fitATEJU _
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Nitn-Nk Suppdv lien: ( itit) /i •' < N N-_ .
t, 11 Recovery 4 Ili-
inleshon Weal fL ft
0 a,;utfer Recharge Oiimunduater Rcmahation
�� `a;t;r Storage°e:Vtsi Recovery 17.SAND/GRA V BL PACK(if applicable)
(('''''''' A0. `+ ery 0Salinity Barnef FROM TO istATERIAL r ttPLACEMENT METHOD
a1,,illic7 Test OStorrnwatcr Drainage (, ft, (C rt, ), !,c j
aEx,cr;mcnlallcchnoiogs O Subsidence Control ft ft
QC,cothermal(Closed Loopi OTnerr 20.DRILLING LOG(attach additional sheets if nacmu.ry)
FROM TO nF_Sf:RIPFION(ado,hande..e•a.tdh.tr4 type.psis,u.+ne.l
1 Cmothei^ui(Heath,='Canton•Return) Other ex fain under 1!?1 Remarks) ,-
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4.Date Well(s)Completed: ) C `( Well iD# R. cj 5 ft C /4-- 1/
5a.Well Locates: rt. 7e. 5 IL ,),.
f� +-� i'�.- ,1 �� ft. ' ft. a �) � -..
- i ft. fL ` ...��..., ./ i.e.4.1
Fuxin)Owner Name Facility{DI(if applicable)
��1, ;- �' raj i*).1a,L L SEf' 2 o Z024,
Ph,sisal Address.City.and Zip rt. ft. I
I,� I:I21.REMARKSIr..0:7t'4.l'-1 a.--•,e4 1'ijr.
Hardened drive shoe. C"`rr",fT
Count) Parcel Identification Ni,.(PIN) _
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
if well field,one tat'long is sufficient) 22.Certific
-i:.cLi Q 940 N ." 72
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6.Is(are)the wells) Permanent or Temporary Si of Certified Well Contractor Dare
0y signing this Dorm.i hereby certify that the well(5)was(Isere)constructed it sec•)..d eee
7.Is this a repair to an existing well: OYes or OX No wort,15A NF.te 02C.0/Of)or ISA NCAC 02('.a1g0 Well Cauctriuti.n Stumarr,h and;eat r
if ma is u repair,PI out Anonn well ramie-action information and explain the nature of the
copy of this recoil has beesi provided so the well tlwnrr
repair under a2I remarks artriin or can she Muck ufthis form
23.Site diagram or additional well details:
k.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site detailsor wadi
construction details. You may also attach additional pa(construction,only I OW-1 is needed. Indicate TOTAL NUMBER of wells It if iieCl sslR
driidud ' SIJRMITTAI.iNSTRII(•TiONS
9.lnutal wemittple ll depthdbelow l audd}su alrranpre-3irlrt uall(n?lnfJ'} (ft) 24a. For All Wells: Submit this font within 30 drys of comotet.en of wee,
construction to the fallowing:
le.Static water(eve(below top of casing: )G (ft) Division of Water Resources,Information Processing bnit,
if muter/oral Is u/sae rusueg,We"' 1617 Mail Service Center,Raleigh,NC 27h'N)-161'
11.Borehole diameter: 6 (in.) 24b. For Injection Wells: In addition to sctidog the form to the 1J ,-cs ,;w ;qa
/I above,also submit one copy of this final ithin 31),doss a' 4t cIin,cirVa a:'.sci
12.Wen tunetrurliun method: V( 1(`I 1 construction to the following'
,I<.aua<i r.nai-,.csLlc,ditto.(pax;,etc)
Division of Water Resources,Underground Injection Control Program,
11llt WA"I t R SE'l'PLY W F: .l S ONLY: I636 Mail Sen ice I•enter,Raleigh,\c "04.-I ti3u
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13a.Yield quoit) Metbud of foal:Blow 24c. For Water Supply Sr Intermits W ett-•. In ad. ,n Li se t'3 .:•:e:darn:,,
the uddresstea) ttbtn,:, also suhniit one ,. nv .,t ths tl-` ian +sty i 1'_ J.,., df
134.Uisiufecun,n type: HTH Amount: 1 (� completion of well i:xutstllusaian Li rife .,pint} 4cu.-.I d4ara5Tatc.L ai the c.iLA;.
where constructed
1pan ti W-I rhnrii C.0 Fluid ilupaituieili cat IBtsiltiiliecii Ica l fiWlut I hsisktn,it W us,It:„tw.e, Ressned 22-2iJ Its