GW1-2022-06663_Well Construction - GW1_20220708

_rr••• %1WL.oAJMUa.AAvl\ne,a,Vtcu taw-ll YorinternaiUse Oniy:
1.Well Contractor Infor/oration:
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Well T�_ FROM r.x•1R..x•.t.fvr.;•fS:-ir :a�i•!.f
CoattactorName TD' DESCEt�'r[QV
NC WellContmctorCertificationNumber i15fOlITERCASiNG foimnlfi wellr ORLIIVER f""ltmble
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ctatess era�eatnr.
mpagyName
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2.Weii Cpnstruction Permit*: MON 'ro mLOn= 71110ERESs A •rstupL
Lfstaff applicable ivefl consuuedon permits(t e..U!G County.S/af4 volaneG eft) fI. % In.
3.Well Use(check well use): n• tt. In.
WaterSuppil'Well: ��17:SGRESdVx s" :"+�"9F _:'liE!ii I B?`i�k,i:Sin4�i't>"•mow• z �sr'ft?'i&e S. +%%bi
OM To Dw►IIsTER . THIC arA
Agricultural 0MunicipaMblio 0 Id. .
3.0etithemal(Heating/Cooling Supply) 131tesidential Water Supply(single) M
TndustriaUConunamial b1gidential Water Supply(shared)
-WARtion FROM. TO MATBRML IIHe C611ffidr DBAMOUNr
Non-Water Supply Well: fZ is
Monitoring Recovery Iti %
wection Well:
AquiferRecharge [3Groundwater.Remediation
lis19iSAND1GRAVEIrPAGK ii'IIe6bie r`�"^}Pf• :.v,;4+s't'�rea3; '�sAA•lit.�c:�:
Aquifer Storage and Recovery OseunityBarrier. FROM To MATERIAL on,
AquiferTest. OStonnwaterl3rahtage
Experimental Technology 13Subsidenee Control ft: fa 4
"thermal(Closed Loop) r3Tcer 10'DRII:Ln�IGLOG ff i'tuaadni5wlibeets'ita' -
Geothermal tia o1'mg Retain) Other( Iain under#21 Remaiks FROMTO DffiCRMICIOx color rseh e!�
0 fa
4.Date Well(s)Completed:-��+J-GZ.Well ID# Ib ib e,
Sa.WellLacation: .R' ( p� •
Fb erNatne _ Faeificy WN(irapplicable)
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Pl�ystcalAddteUss,Cttp,aadZip' fb R .
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County .PawdIdentnicationifo.(PN F7 4.
a .,-
5b.Latitude and longitude in degrees/minutes/seconds ordectmal degreest
(ifwell field,one latflong Is sufficient)
22.Certification:
Ir JUL .0 $ 2022
?u' 'S� f��!-i/yN_ / Sl •cI � �b�.�.,2�(2_W ,.
6.]Xare)thewell(s)�rnranent or 13Tepiporall 31"sorow dwancontraetor l,rji+. ry>; Date
By sfsnrng thrs form,I hereby eerttfy that the to f(s)roar(t—j constricted in aceondodee
7.IsthisarepairtoanexistingWen: ]Yes or f�Pfli� eNrh/SANGICOr2CAIODorISANCtC01C.O=,Ire#Conrdutflw&umjards and thot a
VthfsIsarepakfilfoutkrol-ivelleonnnx0ort.Warmotionanderplafn the natumofthe copYofth&MCOnfhatbUnpoddedtoMeirefoinw.
repab under#2I remarbsectfon or onArbaekofthtsform. 23.Site diag
ram additional wen detalis:
S.For GeoprobeMPT or Closed-Loop Geothermal Wells haviog.the same You may use Ike back of this page to provide additional well alte;details or Well
construction,only IOW-lisneeded.ladieateTOTALNUMBBRofwelis construction detalls.You may also attack additional pages ffnecessaq,
drilled: ',
` SUBMITTALINSTRUGTIO�TS, .;. ' : .'
9.Totalwell depth below land surface: Ida y ( ) 24a.Yor.All Well4: Submit this ifomrwithia 30 days of cohtpletion of,well
FarmvlrlpJewelfrl/stalldapths(jd(�erart(example-8(dj200'arrd1Q1000 construction to the following:
10.Statie water Ievel below top of easing: (ti:)
lfiraterfaveltrabaveea ir►&ass"+" Division ofWaterltesources,Iatrmaton Processin Qrlts`
f�/ 3617MaitService Clenter,Retdg%IgC276991617
11.Borehole diameters (in) 24b.Per Intention Welts in addition to sending the fluor to ate address in W
12.Well construction method:rp 4 e r y above,also submit one copy of skis form within t0 days•of compietiowof melt
construction to the following:
(Le.eases;tomcY.eabin.diceccPusL.eta.) .
DIvislon of WaterResonrces,Underground Injection Control Prognun,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Ser dce Center,Raleig%NC 27699=1636
13a.Yleld(gpm) Method of test: i 24e.For Water SunDly&Iniectlon Wells:`In addition to.sendtng the ibtm to
Ow addresses) above,also submit`one'copy.of this Iona w1d&30 days of
13b.Dislnfection type: �` dr: Amount: t_l Q Z completidn of'weU construction to the county health.dcoatmtetit of the'ceunty
where constructed.
Form OW-1 NotthCaroltnaDepartmeotofEnvitnnmenmlQualityDIvlsionofWaterltesotum' Ravisad221.2016