GW1-2022-02877_Well Construction - GW1_20220228

WELL IrUNa!ltlUtrilUN t'lClrU11U [i7W-11 For tificinal Use(hiy:
1.Weft ractor information:
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14 WATERZONES
m FROM To OES"N'TlOR
�-73 E � o % ga. l!- Gym
NC W t ccniseation Number , a$5 a o
F E B e� (Q ' 15:OUTER CASING md)6 mod: OR lNER = e
�r+,,p fROM TD DIAMETER It
THICKNESS MATERIAL
J IX3 Campany Name ®ft Tel ei .q I�n'" � ' fL B ` ' Z� UO 11L G +
Q/Soii 16:1NNER CASING ORTUBING rttdosed-lou
2.Well Construction Permit3 FROM TO DIAMETER THICKNESS MATERIAL
Listallapplirable�B nperart (e UIC,Comely,SM Uaniza ,fife) fL fL
3_Well Use(check well use): in.
FWater SuPPh►Well: 17:SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft fLhermal(lieati*Cooling Supply) Water Supply(single) ft % in.
striallC amacrcial Oac"dent d Water Supply(OW00 is GROUT..
FROM TO MAZERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 0
Recavay fL It,
Injection well: fL ft
Recharge OCroundwaterRemediation
_ 11 SAND/GRAVEL PACK'rt
StorW and Recovay 0SatinityBffirer FROM TO MATERIAL EMPLACEMENT METHOD
Z Test lStnrmwater DraQiage IL tL
ental Technology OSubside=Qatiml tt �
(Closed Loop) Tracer 21:DRILLING LOG attach additional:dieefsif necessar
FROM TO DESCRIPTION char, soKt . sib
(Ileaimg/Coo6ug Rebun) _Mcr(e#,=muter d21 Remafs) fit fL
4.Date Weil(s)Completed: Well If) � d�� o It /�3 fL a :9104.
8��1- 18�II ' $'5a.Well Location:
fL fL
/Owner Name ray II (ifapplicatle}'- ft tt
Physical Addc-ss,aty,and Zap it R
0u leAg-K 21.REMARKS
'^ 31 PazCel IdeohStal[oIINo.(PIN} = --
5b.Latitude and longitude in degrees(minutes(seconds or decimal degrees: G-ao7 i-
(tt'-mll field,—larnong is saffic+ed} -,� 22 Certification:
N W
6.is(are)the wells) Permanent or Temporary Sigmime ofcertifiea Well contractor Irate
By s pafng this Town;1 hereby cwviy that the nell(s)was(Rare)constructed in accordance
7.Is this a repair to an existing well: byes or ONO with 15A NCAC 02C.0100 or 15A NCAC 0W AM Well Construction Standards and that a
Udds is a repair,fill outfino►m weffewwnwhin IMormadon and eaylaln the nature ofthe copyofthls rerordbubeen prov►ded to the well owner.
repairrmder#21 rmnarftsecdonoronme back ofmis Iona
. 23.Site diagram or additional well details:
8.For GeoprobPAPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages if necessary
drilled SUBMITTAL INSTRUCTIONS
9.Total well depth below land surfacer (fL) 24a. For All Wells: Submit this foam within 30 days of completion of well
Formoldple wells Bstall depths ifdiflerertt(®rumple-3(a)200'and 2@1M construction to following:
10.Static water level below top of casing: /� (fL) Division of Water Resources,Information Processing Unit,
Ifw&rImlisabmeasbrg.we"+ 1617 Mail Service Center,Raleigh,NC 276999-1617
11.Borehole diameter (tn.) 24b. For Iniection Welts: In addition to sending the form m the address in 24a
above also submit one copy of this ED=within 30 days of completion of well
12.Weil construction method: ,(/ constructionto the fi louring
Cie-an,rotary,cable,dnectpusb,etc.)
Division of Water Resourc m!Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mai!Service Center,Raleigh,NC MW1636
r F
13a_Yield(gpm) Method of test Lino24c-For Water Supply & Iniectlon Wells In addition to sending the fort to
the address(es) above, also suI - one copy of this form within 30 days of
131L Disinfectiontype: Amount: /0 'O�- in the camity bcd&department of the county