GW1-2022-07449_Well Construction - GW1_20220810

1.Well Contractor Information:
�n�1/—V��y/�eh G���e< •'lil.•WATERZtINES'.':i;".:ri:•`?,::?:":ri; ?u"'ei: �:+::r::,.�•s•.i: 4��::Frr'S' _i�>;.:c':. .�:
v FROM TO DESCRIMM
WellContractorName
NC WellContraetorCettificat[on Number n n AS5 OUTER:CAMG fo"rinulfi" irell+'ORZIlNER a"'it@iible
l �+ P�J r 9 ZQ22 FROM TO TI ER TTDCInQFSS aTATERTAL
)3.re S l�02 t:t L,
CommrL;Name Z to
r"w.2!?3 Unt, 16:D=R`CASINGORTUBING: eutiieimelbloaed�loo ':.'Gta5i4z:e 4ia.cz�':
2.Well Construction Permit#: /3 161 m;Q;;BOG FROM TO I DIAMETER- 11 TIBCRNESs I DTATERTAL.
Listall oppUcabte ivdl construction petmfts(Ee.WC County.SW4 Varknew eta) ft � i°•
3.Well Use(checkwell use): at ft.
Water Supply Well: ;AV SCREEN�F=. `�:,,v/ s r < t xa•r�;,i,1Xe11 i,•r; XV; xi., <;�i T•..i"l.�.t.�':t:F�:4.'ft. S .t.4 L... i:i. •iG'Yfu. tC:+. 1'v. ..4i
FROM TO 101"WrOt. SLOTSIZE THICKMW aL►TERTAL
Agricultural 13Municipal/Pubtie 0 ft in
_ Geothermal(Heating/Cooling Supply) residential Water Supply(single) R fL In
htdustriaUCommercial E31tesidential Water Supply(shared)
Y18GROUT:sf.i`rF;:.T.•:;.tic,�t:,a/�G;^f9'.•.SrY,i+:'r=Y'si.J'..``i:,;it'� :«iiS`.'•i�`'�iju:�.' +;=.':i:7.%H3e::%:,•i'
hsi ation FROM To MATERIAL EMFLACEMENMEMOD&AMOUNT t
Non-Water Supply Well: 49 ft iG ✓
Monitoring ILA cf
ORecovery
Injection Well:
AquiferRecharge OGroundwaterRemediation ft. ft
s•19:SAND/GRAVEI:PACIC da"'Gea61e�;.•'•�:'�<::i'c4>`s:::c'S::ue`ii�:a�'.::y's•�i.:;v.C�:
Aquifer StorageandRecovery 13SalinityBarrier FROM TO MATERIAL EMeLACEDIexrDIMOD
_ AquiferTest ElStormwaterDrainage ft ft
Experimental Technology nSubsidence Control fa ft.
Geothermal(Closed Loop) J3Tracer iZO:DRILLIl�IGLOG ahaehsdditiowd3bee6i[iiec6sii ':r:�;S»`c:� c:!ti.:' '
Geothermal(HeatingfCoolingRetum) Other( lain under#21Remedts) mom To aFseR>perox eotot;r!l+edner.sotltmek are.eee
D ft to t
4.Date Wells)Completed: -Z —ZZ Well ID#
Sa.Well l,ocatiou: O R' 9,3t R'
iG a ,,
FAc/iIIty/OwnerNime ) _ �- / FacRityMY(fEaapppllicable) ft ft.
fL
,,lh7oh r t
Phystcal Address.City,and ft ft
.121:REMARKS<`i'':' :e�:t�i��ir'.r:�YN;� 'T_yc'.:`c:urY:i�r,':;•'Y tw.;.yp:ty� �;7':•yLi:r,_•t'=v,;,:,'�,.*.� .
—Con°ty rC. Parcel IdentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 22.Certification.,
, f.lN ? W
6.ware)thewelt(s)EIfermanent or [Temporary o b Welt Conttactoc Date
a 2`
y signing thrs form,I hereby eeno that ihe'wdl(s)evos(were)constructed in aceordante
7.Is this a repair to an existing well: Oyes or BNo irlth ISA=C 02CA100 cr ISANCAC 02C.0200 We11 ConirtuetlonStmrdards and that a
tfthrs tb a repair,ftU out ktotm w9construatron rrformstion and cwlaht the nature ofthe eopyofthts reeordkwbeen provided to the well owner.
repair°nder#21 re=rksseedon cr on the back ofthlsfornr. 23.SIte diagram or additioapl 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 OW-1 is needed. Indicate TOTALNUMBER of wells Construction details. You may also attach additional pages if necessary.
drilled• ,SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: d e'� (f`) 24a.For All Wefts: Submit this form within 30 days of completion of well
Forrmdtlpreweffs list alldepthstfd(�erad(esmrrple-3@200'and2Qa1003 cOngiruCtiOntothefollowing:
10.Static water level below top of casing: a (M) Division of Water Resources,Information Processing Unit, I
lfwaterlevd&above oaring.ase+" 1617 MnA Service Center,Raleipb,NC276991617
11.Borehole diameter. 4/. (in) 24b.For Infection Wej : In addition to sending the form.to the address in 2 a
above,also submit one copy of this form within 30 days of completion-of w
12;Well construction rirethod: rA4W"n J construction to the following..
(ie.suger.rotary.eable,dkectpusiy et--)
Division of Water•Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699=1636
r i '
13a.Yield(gpm) J Method of.test: % 24c.For Water Supply&Injection Welts: In addition to sending the form to
the address(es) above, also submit one'copy of this tbrm within 30 days of
13b.Disiafection type: ,f r; 1'e— Amount:_ � C3 Zj / completion of'welt construction toi the county health department of;the county
where constructed.
i •
FormGW-1 North CamlinaDepattmentofEnvimnmentalQualiV-DIvisfonofWateritesoutees" Rawked2-22-2016