GW1-2022-00278_Well Construction - GW1_20221222

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1.Well Contractor Information:
Co �r��ll r.-KMATERZONES`.° __; :- ='ri.+r J: : :t;'Ji•'
Well Contractor ame TO DESCRIPrIQN 1~`
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NC wen o tractorCertificatton.Number
G S �.�,��.,a�-.S �? L- TER-', f fffilti=caseil.weU§ ORLINER a"'Umble
'D5 FROM TO DIAMETER I. T111CHMS MATERIAL
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CompanyName -••
5 D1NF.R'CASINGOR.Tt1BING: eutbdr"meleldsai�lu8 ?:M:'t?[:::.`•it:''.%?;,^'.
2.Well Construction Permit#: Prc�cacTAP.o L OM - To DIAMETER', i TSICKNESS Ust all appitcable well construction permits(La C Counry,Star%Varna Fo& � In.
3.Well Use(checkwell use): R• ft t°•'
Water Supply Well: 17.'SG'REEN'tis " :>:r;;=>:,l;isi;u:5::%i ti!: t!'? •x :1 5?S a :i:.i:-4'�:fi:::
FROM TO " I DIAMETER I SLOTSIZE THICMMS MATERIAL
Agricultural l3bilicipaliPublic 0 ft ft in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft
Industrial/Commercial DResidentialWater Supply(shared) ,.
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Ilii lion FROM TO LACElt41NTM MOD AMOurcr t
Non-Water Supply Well: ft is g
Monitoring DRecovew R ft
Injection Well:
Aquiferltecharge OGroundwaterRemediation I y
Aquifer Storage and Recovery f3SalinityBarrier FROM TO
a"�limcaAti)6};' FSc FLACU M `•::f:e:i:.fs'
METHOD
__ AquiferTest OStormwaterDrainage R !
... Experimental Technology [3SubsidenceControl ft !t
Geothermal(Closed Loop). nTmcer A0:1DRlI:L1NGLOG atfacliadditidnaIsbeetsifaeeeiia t{ S;S J•:r:3=.°?alai 'iH:,
Geothermal(Heating/Cooling Return) nOther(explahtunder#21Rematks) FROM To D Oxeolertranines.aatumek eeta).-
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4.Date Well(s)Completed: 1 n -/- 4 Well ID#_ ! it Arzlit
5a.Well Location: D' ft
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FAcitity/OwnerName _ Facility IDtl(ifappUrable) ft ft• U
ft ft
Physical dress.City,and Zip ��� ft ft
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County Parcel IdentificationNo.(PIN) v C
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlong is suifrcient)
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6.Is(are)thewel!(s)rJPernument or OTemporary SisciftzroofCatmWiellcontractor Date
By signing this form I hereby centfy that,the weU(s)was(were)constructed in accordance
7.Is tbis a repair to an existing well. 13Yes or J}No rvtth ISANCRC OIC.OlW or ISANCAC OIC.0100 WeMCowkvdion Standards and that a
IfthlsIsa repair,fill out/amvn well construction tgfannation and explain the nature ofthe eopyofthisrecordlmbeenpmvUedto the well mvner.
repair under#2I remarks section or on the back ofthisforaL
23.Site diagram or additional well details:
8.For GeoprobeMPT 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 OW-1 is needed. Indicate TOTALNUMBERofwelis construction details.Youmayalso attack additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS {'
9.Total well depth below land surface: (ft) 24n.For All Wells; Submit this form within 30 days of completion of well
Formuttple wells listalldepthstfdljerent(esample.3@200•and2@1007 constmCtionto the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processlog Unit,
Ifwaterlevel is above casing.use+" 1617 Mall Service Center,Raleigh,NC 276991617
11.Borehole diameter: in) 1'
( 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: )a))` 1�DTl�� above,also submit one copy of this form within 30 days of completiowof well
construction to the following:
(ie.auger.rotary,cable,dinectpush,etc.) .
Division of Water Resources,II u]erground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centi r,Raleigh,NC 276994636
13a.Yield(gpm) s Method of test: 24a For Water Su°niy&lniecti In Wells: In addition to sending the form to
the addresses) above, also submit one*copy of this form within 30 days of
13b.Disinfection type: iT 1 Amount:_ �t�OZ completion of well construction to'!the county beaith department of the county
where constructed.
Form GW-1 North Carolina DepartmentofEnvimnmental Quality-Division of WaterRescurm Revised2 22 2016