GW1-2022-09917_Well Construction - GW1_20221031

WILL MMIRUCHON RECa (GW-1) Forhftmal Use ODiy: �.
1.Well Contractor uformation: _
Glare, 1.1!•eickndP_f i+weTERwrtEs....
WeMaDaaaName FROM TO DtSCREMMN i
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NC Well Coadraaor CatifiationNamber ••15.OUTER CASING hrialti w�N OR LUM ' '
M
ft,
5 �n/G To DreMmaR T MST�Iei.
ft
Compem Name i16. CAS[ COR
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2.Well Construction Permit#: ^/ FaoM To Diean*rrn 'r>a»uM mszan sy jv
11staQapplfoabkwaQoaragaet/oapermfts(Ze r.UCCornrty.S-4Ymfa,,Mem) R to
3.Well Use(cheek well use): $ M
i
Water Supply Wen: '' =1 c
FROM TO DIAMLIYR 1ffiC ^.MA1?RiAL
OAgriailhnat OMunicipaU lic R - ft ton
OGeothetmal(HeatinglCoolmB Supp1Y) tiaffm-dential Water Supply(single) g ft In.
OlodustrisUCommercial OResidential water supply(sban>d)
..IRMtOU 'l.: 'y3•,. r•�.:•.•.• �';:,.•.'.t ":{h:>.Lia:�.N��.::.r�.� .
flhii on OWells>100000 �rr GPD FROM TO MAMMUL 0911A Mts>soDa:eesovxr
Noa-Wafer Supply Wem v .R. ft .6
OMonitoring ORecovery 1t R m
Injection Wen:
ft tt ,
OAgrafer Recharge . OGroundwater Remediation
Ig,SAND/GRAY•EDPACI3 d"' .2Me
OAQuifer Storage and fiery OSalihity Barrier FROM TO tvtATaRUL I i INNAC OMPAZIRM
OAquifer Test OStormwater Drainage $ R
OBxperimental Technology OSubsidence Control ft R.
OGeothemral(Rased Loop) OTtacer 20.DRUIMG LOG xgm&additfdmlbhii 'if'"
OGeothemialgeatftqpQxolmg Return OOthet( lain under#21 Rentadrs) FROM TO Dascitip.ngN(solo nW=et ,r,ate
R R
4.Date weu(s)Completed: D— g wen LD#_ 3? 8 ft & .
sec.well LoGllion: a ft. ft
R 8 e
7r s S I'm lk)y ad�l
FamTdyQwner Name F- ty M9(ifappii-Me) & i
tpoa• )oS3 ��G� .. . `GCS NC- gwx R � 1t Inn.renaii�� Ar. M .
Pipti�l Addreu,sty,aod2ip R
(Jl�'Ga1�1tAwM ZL:REbMJ , `_R;x••.�:.
CMAY Parcel Mentificationi No.(PIN)
i
Sb.Latitude and longitude in degrees/minntes/seconds or decimal degrees:
(ifvmn field,owe ladloag is anf dew) 22.Cerfifi7,w„•..,
° 3�,e 3�►'' N ,$ J 1 ' l I t' W 44
G.Is(are)the well(s): fdf ermanent "or OTemporary s>f ofCerriSed WeuCo D�
• BYJfsM Sifil*fomIANYcer*dwdwweft(:)wwOm)cmovamedarammkowwtrh
7.1s this a repair to an es attng wen:' GWis or ONo ISd NGfC 02C:0100 or 15ANCAC 01C.0200 Well Cvn&&umv Smdmds mid dw o copy
Ijtlda f:a �artbraMtr weA oanedraetlon bjornroaon and arpla6r the rmwoe ofthe ofdrs reooirlhat beenprovfded to the wellVM".
vrpab order t'11 teorml s moon or an the bauEof thtsfornt 23.Site diagram or additional wen details:
8.For GeoprobeMPT or Closed-Loop Geothermal Wens having the same You may use the back of this page to provide additional wen oonstruarm info
construction,only 1 GW l is-needed.Indic ke TOTAL NUMBER of wens (add'See Ovee in Remarks BoxI You may also attach additional pages if necessary.
drilled._ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For mu&pk wells An all depth lf&ff~(esmnpk-3@200'sad 2(a)10&) Submit this GW 1 within 30 days of well completion per the following•.
24a. For-All Was: Original form to I Division of Water Resoinces (MR),
30.Static water level below lop of cast>1g: X-0 Ijwatsr lew,l is otiovs o¢rbrp'Kse"+-
(fL) liformatim Proc=siog Unit,1617 MSC,Raleigh,NC 27699-1617
1L Borehole diameter. l! (m) 24b.For Iaiection Well=Copy to DWit.Underground injection Qomiol(Ric)
Prvgram,1636 MSC,Raleigh,NC 27699 1636 _
12.Well construction method: f i
(i.a auger,roicry,cable,dueapwk etc) 24c.For wa la ter Sunnd O n-Loo Geothermal Return Wens:Copy to the
county environmental hearth department of me aunty where i e�
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells rodn' over 100 00 GPD:Copy to.DWR.CCPCUA
M Yield(Epm) ..3,V Method of test: f t Permit Program, 11 C, e' G 11
13b.Disinfection type: H Tlf Amount:_ Jed 2-
- i
Fomi OW-1' North Carolina Depamamt ofFnvitonmemal Qwliry-Division of Water Resources Revised 6.6-2018