GW1-2022-03719_Well Construction - GW1_20220330

I.Well Contractor Information:' 70 3
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WeMntractorName FROM TO I DESCRIMCK
NC WeliContractorCeRtficationNumber
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t FROM I TO DMMM i =CMWZS AMTER1AL
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Compa�Name
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2.Weft Construction Permit#: /_1�df FROM To aw►�rER t I�eIaVEssI MTERiAL
List all app►icable:veg eonsauctfox permits(Ee.MC.County,States Yarlance,eta) H
3.Well Use(check well use): . io.'
Water Supply Well: DIAn1SYElr SLOT SIZE MCMESS MATEPULcultural E3MwdcipaMblfc O id
Geothemtal(Heatmg/Cooling Supply) Residential Water Supply(single)
IndustriaMommercial DResldential Water Supply(shared)
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Imitation FROM I TO MATEMML 1~iEMPLACESIItMMEMOD&AMOUxr
Non-Water Supply Well: p $
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Injection Well: 6 DDd
Aquiferitecitarge DGroundwaterRemedlatiun
Aquifer Storage and Recovery Salim Barrier
ty FROM TO MATERIAL• VOLACMUMMEMD,
- AquiferTest OStomrwaterDrainage to
_ Experimental Technology Subsidence Control R ft.
Geothermal(Closed Loop) 13TraM '�.20.3DRMLIXGLOG attaetiaddrtidn'a1Matfifiiec =,�:iC:il:icW:�!el;`. %:
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4.Date Wells)Completed: 1-Z J A m# � A r a iv n r, ' :
5a.WellLocation: S" Y R• rAn
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Faoitity/OwnerName _ ( FaciligrIDOOrappil-ble) & R•
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Pbysfc 1M*ess.Cft'y>andZip JIL fL
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County TamelIdentifieattonNa.(P"
5b.Latitude and longitude is degrees/minutes/seconds or detdmal degrees-,
(ifwell field.one lat/long is anffident) 22.Certilicatlon:
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6.b(are)thewcR(s)�'Permanent .or Temporary Roameorcufffiewoucanuactar
By s gahrg thisform.I hereby eer*that the ivett(s)ivas(wem)eonsbueted in accordance
7.Is this a repair to an existing Weil: E3Yes or.�o pith 15AMIC 02CA100 or 1SAAVAC OIC.02W Wdl ConmVdibn Stmrdan&and ihat a
.►/thists a regain iUouthnaim tvelleanstrveBon blfarmationand cWhdn thenatvre ofthe ropy ofdrsrecotdharbeenp loyMedto the ivellmvaer.
repatrarder#21 remark seedton or on tha backgfthtsform. 23;Site dlagtam or additional well del tells:
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only 1 OW-1 is needed. IndicateTOTALNUMBER ofwelis, construction detalls.You may also attach additional pages if necessary.
dam' SUBMITTALINSTRUGTI(QNS
9.Total well depth below land surface: / �q 00 Vs.For All Weds: Submit this form within 30 days'of completion of well
Formrdtiplewelisllstal/depthsifdlBaart(aaample-8QIOO:afrdJQIOO� construction to the following:
10.Static water level below top of casing: �/� (M) Division of Water Resources,Information Processing Unit,
lfwateriavd rs above caring.we"+" 1617 Ma91 Service Center,Raldab,NC276991617 .
ll.Borehole diameter: (in.) 24b:For Infection Welia: In addition to sending the form10 the address in f24a
above,also submit one copy of this form within 30 days of compledowof wail
12.Well construction method: r crfwrif construction to the following.
Cs e.anger'.-udy.cab%,duedyush.eta)
Division of WaterResources,Underground InjeOtion CoatrolProgram,
FOR WATER SUPPLY WELLS ONLY: 1636Mai1Service Center,i Raleigh;NC 27699-1636
13a.Meld(gpm) D Method oftest: / 24c.For Water Supply&Infection Wells: In.addition to sending the form to
j the addresses)above, also submit ono'copy of this form within 30 days of
13b.Disinfection type: �?!D/;Il Amount:_ (J 4 2— completion of"well constriction to the county health department of the county
where constructed.
FormGW-1 NoNrCamrmaDepartmentofEnvimumentalQuah'ty-DIvfsio°ofWaterResa=es RmbM24Z.2016
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