GW1-2023-00896_Well Construction - GW1_20230120

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19.SANDIGRAVP,t.PACK(iraoDlicable)
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O'walfaTc,4 OSlomn+vlcrDrainage R. rL
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CGeotitcrmal(Closed Loop) OTmccr 20.DRILLING LO(J attach additional sheen if area
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4,Date Well(s)Completed: I`s Well IDN ft- 1'2 1L i
Sa.Well)Location: /
Fadliry:Ooixr Nurse Faeliy ID0(ifapplirable) ft. D. /(N
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Pl,�sicl Address, tad Zip ft. FL 9i1�06i7'.8,�t• UIN•1i
21,RE51ARXS
r^ Used hardened steel drive shoe,
Cocnq• Panel Identification No.(PIN)
Ch.Latitude and longitude in degrecslminutestseeonds or decimal degrees:
(if++wu1 fold,one 1300ag is su?cicni) 22.Certifteati
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b.1s(are)the well(s): OPerrnanent or OTemporary Srgnalwo ofCertiftcd Well Coatractor a MIC
fly signing this form•/hereby cerafy that tha nell(s)war(wew)contmvied in accrnlaue a rt
'..Is this a repair to an existing well: Oyes or ONo 13A NCAC 02C.0100 or 15.4 NCAC 01C.0100 Well Camtmcaun Standanlr and Ihat
if aFu is a mpair,fdl out brown veil rorutractlon h fornralton and erplain the rmture of the of ddr record har been provided io the%vil avvnec
repatr a:rkr r11 remarkr aerrlon or on the rack of this form. 23.Site diagram or additional troll details:
&For GeoarobcIDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional cell conslrtletion into
corsruction,only 1 GW-I is ncded. Indicate TOTAL NUMBER of hells (add'See Ovice in Remarks Box).You may also attach additional pigs if necessary.
drilled:-, 24.SUBMITTAL INSTRUCTIONS
9.Total welt depth below land surface: .3o r (ft.) Submit this GW-I within 30 days of well completion per the following:
For m»!a,+>lr Y dk tut edl delvhs lfdrfJerent(°sample-J®200'o d 2@a 1007
24a. For All Wells: Original form to Division of Water Resources (DWR),
f O.Statir wllter level below top of easing: 7_n (1L) Information Processing Unit,1617 MSC,Raleigh,NC 27699.1617
!r aJicr le,el is above rvsmb use-i-
6 24b.Far Injection Wells:Copy to DWR,Underground Injection Control(IUCF
I1.Borehole diameter, (In.)
Program,1636 MSC,Raleigh,NC 27099-1636
12 Nell construction method: Notary 24c.For WoterSu 1 and O an-1_oo Gcothcrmnl Re[urn K'elts:Copy to the
I s u,°allay,cable,duca push,era) county envronmealn health epartment of t c county w ere mstalle l
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells trroducine over 100.000 GPD:Copy to D%Vlt,CCPCIJA
13a.1111d{' ) Method of tut:,BLOW Permit Program,16l l MSC,Raleigh,NC 27699-161 I
pin
131r_Dislarectloo type: HTH Amount: 1 1b.
i on:,GN'-1 Noah Carolina Dcp=w=1 orEmitonmcatal duality-Divi,ioa of Water 1(esourccs Ravued a G-]ol a
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