GW1-2023-01754_Well Construction - GW1_20230223

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1.Well Contractor Information:
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14.�WATERZONES`.`,�;=:sk":`t'.;::f?;:i; �?s"ss."t,:�::;.s1�•.r ,i�:=f,•�'l ;:�.u:: �,.i.
Well Contract name FROM TO DESCRIPrICK
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NCWeII ontract�orCeKificationNumber ;15.OUTER:CASING fdrffolti-eiiiediVvedi sOR'LIIVER ris"liceble:wir::i:: .;'.•'-:;
FROMM TO .... D ER TBICIOMS MATERIAL
CompanyName
KKKJJJI/ ✓ D ft. �'ft In. • 5
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1y/ '��/�� Al&-1 IIVSRC&9lNGOR.ITUBING: eufIiee"mnlelmed=Iou ?u s:i:zrita�:'•{v`c.: 4.'
2.Well Construction Permit#• 1/f/ 7 FROM - TO 10101 R. J TMCMESs I MAMMAL
List all a.upUeable well construction permits(Le.MC,County.State,Variance,eta) ft ft. In.
3.Well Use(check well use): fL R• I°•
417.'SMEEN3:�'�'a':�i�a F::'::t%:�:F.x i?i�� :i:�:���., r:�r�:?e�a="ti:�::�i ti'Y{ia•#
WatetSupplyWeU: FROM 170 DraBMM I SLOrSIZE I TMCKNESS I atATERML
.. Agricultural 13Municipal/Publio 0 ft I &
Geothermal(Heating/Cooling Supply) 1311esidential Water Supply(single) R R
htdustriaUCommeroial WesidentialWaterSupply(shated)
hti atioII FROM TO MATERiA% OD&AMOUNT
Non-Water Supply Well: it ft P
Monitoring ORecovery ft ft S 1
Injection Well:
fL n3. '
AquiferRecbarge OGroundwaterRemediation 1- K.eA!•...:., .�t:•:-mi-••w•
19SANDlGRAVECPACK de,'""liable , r:.��;�•.,�:,.:•:�.,.....+ate.:,-z�s-::+:=u:;;�:s:4
Aquifer Storage and Recovery OSalinityBarrier FROM I TO MATERIAL EMeLACERMOTUMOD
_ AquiferTest OStormwaterDrainage R ft.
lixperimentalTechnology 13SubsidenceControl ft. ft
Geothermal(Closed Loop) �Tiacer `:20MRIOLLI IGLOG afCaeHsdfidU alabeetiifiiEe`nsa
Geothermal FROM TO DESCPJMOM(eetar bantnemsoram sar.ele)
(FIeatinP�CoolingRetum) Other(explamunder#Z1Remarits) Oft ! it .j0
4.Date Welt(s)Completed: / -a Well m# R ft 1 e
Sa.Well Location: ft 9 ft �-
r�' ft ft. Il . rp
FacEitylOwnerName _ Facility ID#(trapplioable) ft 0 ft q/ J l
Ml-;� 4MI60P mA� RAM ft
Physi Address,CQ.y,andf t,ip ` p W q grit
11TRCY1lA)t[1J' i Yi,1Yti.i•�4�Y:.irY.`: blu f � `�' ��✓3f•`T!••'di.:t^ .7: w=
County Paa:elldectifioationNo.(PII) ' " �` r ^• ^� -
5b.Latitude and longitude in degrees/minutes/seconds or dechnal degrees: C '�
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(sfwellfield.one]aViongissuffieient) J' `
3 O / 22.CertificaBon:N V o��G
6.1S(are)thewelt(s)OJre"ent or [Temporary Sigwilaeof etti6edWelContraetar Date
By afkarag this form,I hereby eeWfy that the welf(s)seas(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or No rvlth lSA=COZC.Ol00 or ISANCAC OZC.OZ00 WeUComhuciron Standards and that a-
Ifth/slsa repakflUoutlarosmivalleonstructlon Inform otlonaaderplain the nature ofthe eapyofthRrecordhasbeenpraddedto the'wellaimer.
repalruader#21 rentarkssecdon or on the backofthisform. 23.SIte diagram or additional well details:
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 GW-1 is needed.ladicateTOTALNUMBERofwells construction details.You may also attach additional pages ifnecessary.
dulled. i SUBMITTALINSTRUCfIONS
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9.Total well depth below land surface: ( ) 24a.For All Wells; Submit this form within 30 days of completion of well
Fortmrltlplewellsltstalldeplhslidt,ff rent(exampla3@200•and2 a@1001
�� cartshuctionto the followiug: 11.
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfwaterlevel fs above easing we + 1617 MR Service Center,Weigh,NC276991617
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 form within 30 days of completion'of well
12.Well construction method: l� construction to the following: I
(Le.auger mtary.eabte,dkcctpusb.eta)
Division of WaterResources,Undetgrouad Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 7' 1636 Mail Service C�n Jer,Raleigh,NC 27699-1636
13a.Yieid(gpm) Method of test: �� ( 24c.j:or Water Suouly&IntectfbniWells: In addition to senf'r-
y- Q J the address(es)above, also submit one'copy of this P.-
13b.Disi ifectirontype: / Amount: v O` completion of"well construction tot, county heO..
where constructed. I
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FotmGW-1 North Camlina Department oMvitonmentalQuaMy-DIvisionofWaterRessources tl
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