GW1-2022-00283_Well Construction - GW1_20221222

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'1.Well Contractor Information: jl
n �, �!.. �. ��� y!�(,�// 44+wATERZONFS :;r:::..::::.;;rrt:;:•
Wel[ContractorName �r FROM rTO rMCRIPrICEV IzJ
NCWeUConhactorCettificattonNumberft. ft � f I
�15OUTER:CASING forinnl4" e1Cv R'•L1NER is"lic`a'bte°:'-':�r-�i.,.:�;-r'
FROM TO DIAMETER i THIc[INESs MATERIAL
CompanyName t' 7f 1 �L R ft. ini I3 7.5
t16 INNER'CASING 0RTt1BING:'eot[iermaleldsed-luo :tti;:;?C •`i; `<'�3v
2.Well Construction Permit*:_ /®t')/J7 J Z FROM To Dt AMM C 1i THICKNESS I MATERIAL
Lfst all applicable iveff construction permits(Le.WC County.State.Variance.eta) ft iw
3.Well Use(check well use): % ft' in.
WaterSnpplyWell: :17.SC1tEF�P3:i ':Y: r),,:: t=:L"u Ft •:ii:i'emu;;rw:S::3g cniYe:t C�SS`,•'.:e ;.';?
FROM TO I DIAMETER SLOTSiZE THICKNESS MATERIAL
3. Agricultural 13MumcipaUPublic 0 ft ft in.
I.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) S ft
rind 'al/Commercial DResidential Water Supply(shared)
_ �l&GROIITI`�r% >Xc;:;:*,�':,ari's :::eE: 5:is •ai'R a 7 `':'Y:C-:'•'i;r'�+:�iiiY.%i: :i�`::
8tion FROM I TO MATERIAL EMPLACEMENTMEMOD&AMOUNT
Non-Water Supply Well: ft R ddy
Monitoring DRecovery iG ft
Injection Well:
iG ft I'
3. AquiferRecharge OGroundwaterRemediation
Aquifer Storage and Recovery ty sOSIAtVD1GRAVELPACKa'"]ieabif 3:3
�Salini Barrier tStATER1AL � EMPLACE6iENTMErnoa=•
__ AquiferTest 13StonnwaterDrainage R R
... Experimental Technology 13Subsidence Control ft ft it
gGeothermal(Closed Loop). 137racer =20:DRII:L>riGLOG attiicfisdditiSiialabbetsifiiiieasa" ems; :> -�iti ;:ii x<
Geothermal olingRettim) nOther(explain under#21Remarks)I FROM To DFSCWnON(cororbardneu.solVmek sae.eta)
o ft 7 ft (gam
4.Date Wells)Completed: �,1 2�a- -Well WN ft. ft
5a.Welll,ocation: ft GG R' K p
G i ft ft `7. c I u F V.�.+:
Facility/OwnecName _ FacltityID#(ffopplieable) ft ft
LL,, % IL 2
PWcalAddress.J City,an/Zip Z 8 ft ft
�C C.
f /c�rI 6U 4 dSl "J�J —Q Z 2LREMARICS a?.i:= :ti=f"£;c .%is• `:c�l:il•}�
County TareelIdentifleationNo.(PRE
' II
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
('dwell field,one latilong is sufficient)
�+, 22.Certification:
Z `��' 42, .3Oj�6'tN �l C�`;1/s rt,0',q�;k n W it
6.Is(are)the well(s)OPernlaneut or Temporary Si of ed WeU Canhaetor
Dft
By signing this foray,I hereby eeno that the ivell(s)was(were)constructed In accordance
7.Is this a repair to an existing well: ]Yes= or E • with ISAMIC01C.0100 or ISANGIC OIC.0200 Well Construdion Standardsmud that a•
lfthts[so repair,fdloutknownwellconstructionWgrmatfonandewlatnthe nature ofthe eopyofthtsreeardhatbeenpmddedtothervel%comer.
repafr under#21 remarks section or on the back o(Abflrm '
• 23.Site diagram or additional well de¢arls:
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 TOTAL NUMBER ofwells construction details.You may also attach additional pages if necessary.
drilled-, SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface:_ �'G (ft) 24a.]For All We114: Submit this form within 30 days of completion of well
Fortmtltlprewellrlistalldepthslfdffliaent(exampl-3 00'ond2 10n construction to the following:
10.Static water level below top of casing-. '0 (it) Division of Water Resource's,Information Processing Unit,
lfwaterlevel is above carts&use+" 1617 Mal Service Center,Raleigh,NC 276991617
11.Borehole diameter: (in) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this fomi within 30 days of completion'of well
(Le Well construction method:_ 01�r�/ia auger,mry ta ,eabie,di¢ctpusly eta) construction to the following.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY. 1636 Mail Service Centj r,IRaleigb,NC 27699=1636
13a.Yield(gpm) - Method of test: 6' r 24c.For Water Suooly&Injection W I iIs: In addition to sending the form to
the address(es) above, also submit oae(copy of this form within 30 days of
13b.Disinfectiontype: 1' o Amount: completion of'well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina DepartmentofEavim=entalQuaRty-Division of WaterResourees Revised222 2016