GW1-2022-10488_Well Construction - GW1_20221118

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This form can be used for single or mul[iple wells For lotemal Use ONLY_
1.Wel! Ontr?cfor Information:
I /lR{ tA.W/iTEItZONEs
Well
lCC'ontr((a=rtorName FROM TO DESC"Rumoll
NC Well Contractor Ceti6eat;on NUMLx a50 f t ',�� f t r .
'IS.•DOTER.EASiNG for�ol'. .wt:l(s ORIdNER'rfa liralile• ..
[3�117Cne t�(e Moog IMU-500ingy one. .FROM � TO DctiMEnR nuctav�ss MATERLIL
Conrpaay Name ft C r(C in 7i� •2 i �VC
yt ]'6IIT1Y>�K.CASIIV�•OYiTUBING Me riaLVdased3'
2.Well Construction Permit#: �7/`j RBOM To DIANE-MR 77RC�p�q
List all applicable well construction permits(i.e.Cmmry,Slar4 Trarionce,etc. ft 1KATcoI�r
fl�
3.Well Use(check well use): ft. ft
is
Water Supply Well: �Z:SC1tEEN
❑Agricultural
FROM TO DIAMETER SLOTSIZE THICKNESS 9tATERLIL
❑Mtmicipal/Public• ft in,
❑Geothermal(Heating/Cooling Supply) IRRmidential Waters Su
pply y(single) ft ft is
❑Industrial/Commercial ❑Residential Water Supply(Shared)
Dlrri anon FROM TO RfATFniAT mg CEBtE TmftmOD'&AMOONT
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery ft fr.
Injection WOIL
ft ft
❑Aquifer Recharge ❑GroundwaterRetnediation ;pAClC f: Gt61e
❑Aquifer Storage and Recovery []Salinity Barrier FROM To EMPLACEMFN'fMEfHOD.
❑AquiferTesF ❑SrormwaterDrainage it � MATMEYAL
❑Experimental Technology ❑Subsidence Control ft ft
❑Ge4thermal(closed Loop) ❑Tracer '21111 LimG'I;OG:sttaeti:�dtti6o6iifalteeEs:ifuec�sa
❑Geothermal FROM TO DFSt1tIPTION mlor,6arrin soillruek ':'`a±ere dc'
(Heating/Cooling ❑Other(explain under#21Remarks D ft 2— ft --
/�
4.]Date Will(s)Completed: Q� �ZWe11-IlD#1 T7��r � R to ft
-
a
Sa.Well Location:
L`�rt tnJ� n
La/t'L, /Id", 1- ft `3oo ft
raetuty/G1wtxxNarrie ID ftft. Fj
Al
Facility J'(if dpplieablbj
Plrysical Address,City,and Zip J` f- ft C L�et cn/\
County J`
Panel TdeatificaUut No.tft) r t^'+
5b.Latitude and Longitude in degrtWmiuptes/secouds:hr detama[ilegeees:(tTtvell field,one Jatnong is samcimt) 22,?2h Iron:
G
6'Is'(are)'tlrewell(s): 13P2tvranent, or ❑Tearporaty S ofCat�edWell'Contractm Da
�� By sigrrfngihis join L hereby certify char he.weil(s)was(were)constructed in.aecordmce 7_Istbis•arePairtoanexisting:well: ❑Yes or Edo with•ISii1VCi1CO2G.Od00orI3ANCtICOZC.0200,We/lCantrr/dtlohStandarrlrmidihdJa,Iftbisisarepo!,filloutbrownrvelJconsrrucrionirrformaGonamderplirrnthenoture•ofthe k���harbeenRmvidedtotheseal!owner.
rrprtlrunder921 remarh•section or on the backofihlsform.
23.Situ d'iagcam or sddifibrialwell details:
&.Number Of-wells.constructed: ✓ YOU titay rise the back Of this page to Prdvidc additional well.site details or well
For mutrip(e injection or non-worersapply wells ONLywith lhesame cons nc&V, bdu��on dells' You Way also.at aeh additional pages,if n ry ecessa .
submifoneform. you rare
SUld1p117<"JCALINSTUCI'iONS
9.Total'well depth below land surface: 0
Aormrdrrple weUslistoJJdeprhsijdr�eretit(ermrtple-3aQ200'mrdz 0p (ft)' 242.For All W.elis Submit this form within 30 days of completion of well
Ql 9 cdnstiuetidn to'the fdllowing:
10.Static water level below top of casing: 2 (ft) IDivisiOn of Wftt"Itz ity,Information Processing Unit
Ifwarei•level is above casing,use"+^/ E617 Mail Setvica Center,Raleigh,ITC 27699-1'617
11_Borehole diameter. t/���]] inn) 24b_For IniectYon.Wens: In addition to sending the form to the address in 24a
12-Well construction method: 61/ R i t J above,also subnriE a copy of this form within 30 days of completion of'well
(i.c urge,rotary,cab7q direct pusl>,ete.)
0 J cantimbdon to the following.
FOR WATER SUPPLY WELLS ONLY: Divisioti•of Water Qnality,Underground Injection Control Program,
1636 il5ail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method offtsE BIOWn20 MinllteG 24m Fo!-Wstei.Snnnlst dt YniectioTr Wells In addition to sending the.form to
HIM fhd addresses)above,also submit one copy of this fofm Within 30 days of
136.IDisinfeciion type: Amount: V2 CUP Completion of well consfiVetion to'the county health department of the county
where constructed.
Form GW-I ! North Carolina D eRrbneot ofFuvi=r=t and Natural Resources—Division of WaterQuality Revised Jan.2013