GW1-2022-03720_Well Construction - GW1_20220330

1.Well Contractor Information: L(-7 U 3
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WellcontractorName DFSCU'TIIN
av o t
NC/Well Contractor CetttfirationNumber •s153O11TER:CASRHG foimWttcasedwelL� ORZiNER s"'limbl6't,i.�=::>;;';>
FxoM � zo � aw:�rett i0.i zstctaorss ntnpTetttnr.
CompanyName � Z / y
"'.3 MIIVER'CASINGOR.fl71SING: erittiermal"elo"sed=lod :.'C��s��.,:,? :�s:S? e.et'•:i:
2.Well Construction Permit#: [,�;AMSCREEN--Ilr
o'1 To D10mmR TmCKMS ntATERtnL
List aU applicable rveUeonmuction permitsAe.fIIG Couruy,State.Parlance•etc) n• ft.
3.Well Use(checkwell use):
Watersupplywell: .'.y".''��PC 13:L'"::tncs�ta=�S 'u:4�x 4y . ....OM TO DIAatETER SLO•rS1ZE I TMCMUS I IItATERU►L
'cultural []MunicipaUPublic • 0 ft n in,
Geothermal(Heating/Cooling Supply) E31tesidential Water Supply(single) % fL
hrdushial/Comunercial Residential Water Supply(shared)
9185GR0Ut't'z NNisseti•p^'.�f
kri tion FROM TO MATERIAL EMPLACEB1F"MMOD&AMOUNT
Non-Water Supply Well: . � y,
ft
Monitoring DRecovery R it
Injection Well:
AquiferRecharge 133roundwaterRemediation Zo e)
t19:tSAND/GRAVEtiYAGiC
Aquifer Storage and Recovery 0SalinityBarrier FROM TO MATERIAL EMLACEME INErriOD
_ AquiferTest OStomtwaterDrainage & ft.
ExpedmentalTechnology j3SubsidenceControl ft /R
Geothermal(Closed Loop) Tracer `:20:13)RILLING LOG sttaeh ad666°`s ARtilfiiee6s6
_ Geothermal(Beating/Cooling Return) nOther( lain under#21 Remarks) FROM TO DESCRWnGNY color hmdneu,soUrroek drs.ete.
�fb IL
4.Date Wells)Completed: 2 2w Well wo ft. y`, ft, _
Sa.Well Location: ft.& t1 d t;
�, iG iw
Hetliq•/OwnerName _ Facility WX Qfopplicable) n n• '
IFL
PlrystcatAd&ess,City.snd�ZV !� ——� & it
.� G 3 J y y) 521=1ZF117ARKS:.<.;:.:::t�;:�:.3�.r...:�.'I�"e'•.�:f�i> i:h� .t..::...a,.:
County Pamd1dentlficationNo.(Pn
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '^
(ifwelifield,one ladlongis sufficient).
22 K ,i
.Cerglication;
z'fs, -�, 1 c' �s�-vaZl��S/y�` SD, OI G�' w •'
yy J 944
6ais�re)WeyveA,Y) raanent or Temporary SrgG�eeo Well traetor Date
r By sivang this form,I hereby eve dratat the rvdl(s)was(were)constructed in aeeor&nce
7.Isthis a repair to an existing well: j3Yes or whh ISANGtCO2C.01W or 15ANCAC 01C.0200 Well Consdsrdton Standmr►s and that a,
.(fthitisa►epafrfrU out hnotvnwell construction Wormallon and eeplafn the nature gfthe copy aftfiDrecordhasbeenpravldedto the well omter. '
repafrunder#21 remark secdon or an the backofthtsfornL
23.Site diagram or additional well details:
8.For Geoprobe/DPT 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 NUU BER ofwells construction details.You may also attach additional pages if necessary.
drilled• SSUBMITPALMMUICTIONS• .
9.Totalwelldepth.belowlandsurface: 24a.For All Wells: Submit:this form within 30 days of completion of well
FormultlpleweUs/trtelldepthsjJ'd7jerent(—arple-3®10o•mtd2(a1100) con.qructiontothefollowing:
10.Static water level below top of casing: do (ft) Division of Water Resources,Information Processing Unit,
Ifwateilevelfs above cash►$use^+^ 1617 Meit getvlee Center,Raleiph,NC27699=1617
11.1lorehole diameter•. (in) 24b.For Infection Wej : In addition to sending the form to dmzddress in 24a
above,also submit one copy of this form within 30 days of compledowof well
12.Well construction method: 'r��i 4 r V construction t0 the following:
(igaugermmey.esbte,diceetpusb,etc.) .� r _ ,
DIvision of Water Resources,Underground Injection.Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Rafefgb,NC 27699=1636
13a.Yleld(gpm) Method of test: 24c.j:or Water Supply&Infection Wells: 1.addition to sending the form to
the addres(es) above, also submit one•copy of this form within 30 days of
13b.Disinfectiontype:�An'np_ Amount: �� D Z, completion of*well construction to the county health department of the county
where constructed.
Form OW-1 North CamlinaDepadmento7avim°meptmtquaMy-DIvLionofWaterResousew Revised2•d2-2016