GW1-2021-07467_Well Construction - GW1_20211116

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1.Well Conftactor Information:
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-M.WATERZONES
FROM TO DF9CBiPT10N
Well Contactor Name RIt
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NC ellConhadarCatifirdtiaaNtrmber
L5£OUTERCCA mal8rn s[d.wells(RLIl�R
l o FROM To DIAME1IIt' THICSTff39 MATEatTAL
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2-Well Construction Permit#:� ,� FROM I TO I I)MM61E8 MOCK MATERIAL
List all applicable well construction pAnits(Le.UIG Carudy,Statg,Variance,etc) D` It,
3.Well Use(check well use): R' m
wa CREEN
Supplyweli: FFRO DIAMETER SLOTS= I IMCi MESS IMATERUIL
Agriouttural M®icipal/Pablic It. & in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(Slagle) it. & is
IndustriaUCommercial Residential Water Supply(shared)litigati - - -
on FROM I TO MATERiAL LACEMTMETHOD&AMOUNT
Non-Water Supply Well: rL ✓ O V
Mamitoring Recovery lZ %
Injection well: R
EGeotheroad
Recharge E]Groundwater Remediation
15:'SAND/G1tAVELPACg�a k -- -- -
Storage and Recovery Salinity Barrier FROM To MATERIAL EI►fYt.ACEMEl71'MEIHOD
Test [3Stormvrater Drainage R
ental Technology Subsidence Controlmal(Closed Loop) _
Tracer ZO:DRILLIIWGLOG attaehaHdfHomalifFROM TO DESC6WMN=Iw 2GWnxk etr-
Coo" Return) Other Isin order s121 Remadts Q � 30
4.Date Well(s)Completed: _u_a.o well llD0 O M GG fL �/�/
Sa.Well Location: tt. ft.
IL
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Facility/Owner Name FaeaWWM#(ifapplicable)
MCI �f Ids � � r IVEL
Physical Adder.City.and Tup
41/ oin y �`t 59s13, 71."1LM WS:
County Parcel Mea iea ienwo.(Pn4) BWR 61-6'haN
5b.Latitude and longitude in deg mes/minutestseconds or dual degrees: "'FORMATION' PROCESSING
(dwell field,ore laVlong is suffciem) 22.Certification: 7—'7
N W42-&Z4 r, -1, . -d
ermment or em Si of Garton Date
6.Is(are)the well(s)� � porary
By signing this form,I hereby eertrfy that the weff(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [)Yes or 13No with 1SANCAC 02C.0100 or 15ANCAC 02C.0200 IVeH Cornstruction Standards and that a
If this is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under421 remmits section oravn the bactofthwforn.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wens having the same You may use the back of this page to provide additional well site details or well
construction,only i OW-1 is needed Indicate TOTAL NUMBER of wells construction doWls. You may also amrh additional pages ifnecessary.
drilled- s SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: a d U (fL) 24a.For All Wells: Submit this fora within 30 days of completion of well
Formultfple wells list a►l depths if different(exmnple-3()a 200'and 2®1005 construction to the following"
s
10.Static water level below top of casing: (Yk) Division of Water Resources,Information Processing Unit,
If water level is above casing use"+" 1617 Mail Service;Center,Raleigh,NC 27699LI617
11.Borehole diameter. j (In) 24b.For Infection Wells: In addition to sending the form to the address in 24a
n above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ,A construction to the following.
(Le.auger,rotary,cable,dire-posh,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 276-W1636
13a.Yield(gpm) _ Method of test 14,✓ 24c.For water Sbiply&Injc�fion Wells: In addition to sending the fort to
1 i the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: M7 r i-r Amount: 16! 0 Z completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Dqm meat ofTmvimnmentol Qwhty-Division of Water Resources Revised 2 22-2016