GW1-2021-02565_Well Construction - GW1_20210507

WELL!Q0NSIHj9; 'I4N RECORD,LCW-1) For Internal Use Only.
1.Well C draeter Information.
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Well Contractor Namre, TO aesttIon
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NC Well Contractor C rufication NJ1urb/orJ j�
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Company Now
2.wen Conatrtrt tine,Pernttt X. d —06/jzl is ° TO T1 aom MATtt6UAL
Lint all g*imbk mW caminicdon permitsft.*.UIC,Cowry.State, variance,etc.} R. !t. is.
3.well Use(ebeck well use): % h.
Water Supply Well: 9 SCRUP
Stom TO DL&M E n V"trio THICUMN MATI<YiAL
Agricultural OMunicipad/Public n, ft. In.
tbcautai(Hosting/Cooling Supply) esidential Water Supply(single) It rt hL
�ial/Commerew Residential Water Supply(shared)
on FlOM TO KATSttAL RMPI AMMIn etgTROD A:AKOUNlT
Noll-Water Supply Wen: tti
Mondtorin Recovery tL !t.
INJKUM Well:
ft. 11.
Recharge Groundwater Remediation
Aquifetm
r Storage and Recovery Salinity Barrier FROM m MATeatul 611P1.ACrdUA"r M[THGD
4quifer Teat [3Stormwatar Drainage � R-
d3�imentai Technology OSubsidence Control ft. IL
(Cloned Loop) Tracer R
Geothermal Coo' Return Other( chin under 1Y21 Remadta t TO D153 t MONi aver, asWmk elegy_
f n ft.
.4.Date Well(s)Completed:,-/�` l wen mo LL R.
•:!4a.Well Location:. - R' �.
REGE
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FastLWOwoerNatne .„ Fetcility@N{ifbpplicpbk}• ti. R
MAY
,22
11
hyaiwi city,and zipfL
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C-MW Parcel I&Wifieaton No."D v
Sb.Ladtade and lonEitude in degrees/minutes/seconds or decimal degrees:
(ifweu geld,ace is sufficient) - 22.Certification:
N %�/7 W
6.ls(are)the weB(a) erlmmnt or 13Temprary Signature of Contactor Date
By swdmg this form,!hereby certify roar cite rev//(s)%w(were)conatrreiel in acandance
7.Is this a repair to sin eziating weU: 13Yes or o **A 1 SA NCAC 02C.0100 or 15.4 NCAC:02C.0100 tired/Con owdon.Standards and chat a
ro thre rmvrd has been
.(jthLs is a repair,,flll out bwu+t x�ell conetraectlon infor:rwttan ego/cin the rwturY of tilt PJ''of provided M the yell owner. _
repair ruder#21 re,&%*sactfon or on the,back of 6W form. U.Site diagram or additional well deRalls:
8.For GeaprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
cyon''sJtruction,og])�y, /G I is needed. Indicate TOTAL NUMBER of wells Construction details. You may also attach additional pages if necessary,
dri : $131 ITAL IINSTRUGnom
9.Total well depth below land surface: fL) 7Aa, For All &&: Submit this form within 30 days of completion of weft
For mrlttpk wdk 1411 all depths;fdVdreW(avanpk-3(a3100'and 1Q1M ountftwtion to the following:
10.Statle water level below top of casing: ' YL) Division of Water Remoar
/f rom kyel to above aoatg,we.,+., 1617 C 2 644-1617
Mali 3erviee NC 7 e��
11.Soreiwile diameter.
24b.For Insertion I&W In addition to sending the-form to the address in.24a
above,also'`aulm it one copy of this form within 30 days of completion of well
13.wen s opatrsetba method: tionsnuctioa to the following:
.(i.e:aysrir,-rotary ceble,.dext.peuh,etcJ ,
Division Of Water Resources,Underground Injection Control Program,,
FOR WATEA$UP1P[.Y WELLS ONLY: Division
Mail Service Center;Raleigh.NC 27699>1636
13a.YkM(Ww) Method of test, 24c.For Water 5uooly dr lln-fectlon iWellas'In addition to sending the form to
the address(es) above, also submit tine copy,of this form within 30 days of
13b.Dlaiatectioa type: Amount:J letion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Departrueut of EnvironnnoW Quality-Division of Water Retowoas Rtrvised 2.22-2016
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