GW1-2022-09950_Well Construction - GW1_20221031

I°1L CON TION i E-C Rt2(�1) � For Internal Use Only
1.Well cam traebr Inbrmat em --- --� ----- -----
"Aft SDAM
Well Ccmtrtaar Nun tt. It
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NC jell Cootrsctor Certificatioa Numberie- �J ?, lI3lSA ft ft.
C.AI�IYG rfar mum-xaesd a fJ l(.LI�iILt P!f�t _�-- --
..six=*�� t 1'O D[AAtE'r63c b�iS;KNR88 !.M.l4 ..•-.—
Compstty Nsare L4]tt 841tt _
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tlUl1�'tSBt 'O�CKA'L� dtst'f��R1AL
2.Well C.aasiruction Permit � O - It
List all ct*ioabta well eonsbw:lion penstts(i.e.UIC.C mary,5mze. Varia=,ex.)
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3.Well Use(check well ass): _ _ —
W0ater Soppty Well: _ _
t►l2om TO 1 TKR stow StrJa �ua�c��s htAt�IhI
Agriculmral OMunwipaMblic R h. is. -
Geothcrmal(Hading/Cooling Supply) esidential'Water Supply(single:)
lndustrial/Commsrcial Residential Water Supply(shared) t
}yrci em _ Matsu an %A Bt�er a.ea r�ttetttl_____r�rae>9�n[�ourrl
Nob-Water Sappy Well:
Mowtottag
Well:
Atlui€er Recharge E)Groundwuter R.emt dmboa
Aquifer Storage and Recovery (3Salinity Be rier tit Yo btA'!ffiRtsRI C� "1T n
Aquifer Test O Stormwate.r Drainage R' � —
Rui ---+
ExperirnmW Tachnology OSuhaBdenee Un,"i ►�• rt — —___ _!
Geothesaobi(Clased Loop) �'Cracer b� 0g8I9.It iPlta attaeid taltetMOsaeal i9seesi K�— r ___.._ e.
Heatin Cooliu Retutu Other(explain wtdei ir211 R s1 i mom ro It.
4.Date Well(s)Completed: Wei[LIMO _ _ n rt �—
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S&Well l,CaaoS: ------ — ---- -_.e-
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Facititylowow Name Facility IBM(if applicable)
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Pbysiml A, ,,City.and Zip ...�.�
CMW Paroel I&Wificadoa Nc.(IIIN) -
Sh.L.atttude nail longldedee IB degreWminutes/seconds or decimal degrees: ------_- --- '=)
(ifwell field,Gas lat/loag ie sufficient) 2L CerdlIcation: ,
6 Is(arre)the wedl(g l'erm�uemst or E)1emporery StpAttae ofCatified Woll Contractor Mac
By sighing this form.1 hereby-Y.40Y.hat the WWI($)WM SKIM)eowmwftd in wwrdaace
7.Is this a repak to an etdsdall Weil: OYes or IDNa wd(A 15.4.NCAC 02C.OjOO or 154 NCAC 02C.0200 Well C,restnsr&W.Tkmdtrda and dies a
tfrhis is a mare,fill out kaowe well'wMeructten Wo' rAeatiwr esgtauz the nodar of 1he copy of chants—d has barns prow kW 1n Ao cell owsnrr.
nVaIr muter#21 rrsxw*socYiPm or oa the back ofsMs form. 23.Site diagram or addidonO well detaW:
R.For+GeoprobaMPT or Cie"-Loop Geothff mal Wells having the.same You may use the track of this,page to provide additional well site demiis or well
construction only 1 GW-1 is needed. Indicate TI OTAL NUMBER of walls construction details. You may also attach additional pages if tsuc:essaty.
9.Total well depth below land surface: - - - _-OL) 24a. Ay @pew: Submit his form within 30 days of complrtirm of well
For nudel*wails lies all depths y doravn:(ecwnpte- fa�200"a,ad 1.(iy100� construction to the following:
10.Static water level below top of casing: ,L`�_ __ (ft) Divlsioa of Water Rt wureem.infor:sastion Processing Umlt,
YMMr le>el is abuts eaFft We.,+" 1617 Mai151errice(saner,Raleigh.NC:27699-1617
11.Borehole diameter: (in.) 24b. : m addition to sending the form to the address in'24a
/ above,also submit one copy of this form within 30 days of completion of well
12.Well eotsatruetlon method: .�� _.� __ construe Batt to the following:
(i.e.sins,teusy,cable,dot push,etc.)
�._ _...._.. YDivlslaa of water IRewatr m,Urtkrgratrnd Injection Ceatrol Ptvgraat,
FOR WATER SUPPLY WELLS OKLV: 1636 Mail Servicr.Center,RRbigh,NC 27699-1636
13a.Yield(WM) Method of tat:/ L��?-- 24c.For d'+'a_tsf� n��Lni�nctiott V4elis: In addition to sending the roam to
the addre*n) above, Plana subtriit one copy of this form within 30 days of
13b.Disis&cdon type:_ �tnmoaat Y completion of well eoostructiou to dte county heWth department of the county
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Form OW-1 NtM: Carolina Beps+aunent of Enviro:tmrr.W Quality-Vivieaoa of Water Reeanroea Revi"2-22.2016