GW1-2023-02330_Well Construction - GW1_20230331

LL 0 S ON RECORD G'96'-1) For Internal Use Only:
-_J
1.Well CODirattor linfornsatlou: -
ed t'in_ A P /.B el C. i ' . tie WATY21 ZONES
FROM ei!Contractor NowTO DitSCRIE rnON
6 9 3 ft. ft,
NC Well catasaractor t.nitifiatttacn Number `IS;win CASING Mir tack m tit LEMER Ifir:Via)
/Q f / J MOM TO D1AM = MOM.S MATERIAL
(ttJtti$ �e 'S 1 „� '/1✓17 I n'„35 ft' ,hales in. ! , IlTza>/ve.
Company Name
NOM CASING OR fsej)e
2.Well Cesstraetion Permit f: f., ..).-r/, 3 S FROM TO , DIAMETER TRIMNESS MATERIAL
LLtt all epplicabk well oovcuction pored s(Le.UIC,County,Stine,Variance.etc.) ft. ft. fa
3.Well Use(cheek well use): `t. f• ha.
Water Supply Well: 7
FR®A! TO DIAMETER SLOT SLU TRIMNESS MATERIAL
❑Agticultuunl °Mu nicipal/Public ft, ft. in, ' -
°Geothe rmal(Heating/Cooling Supply) eilResidential Water Supply(single) - ft. ft.
!Diindustrial/Comrnercial ❑itesidential Water Supply(shared)
Obi Lion °Wells>100 000 GPD -t ol♦s TO MA1>r�tAn tt1ks71 CgM NT ti1ET1hOD&AMOUNT
Net-Water Supply Well: l it
< 1 r t�
DMa titering OReeovery ft. -' 1
i
Injection Wdl:
ft. f._.
°Aquifer Recharge °Cm uodwater Remediarion
10.BANDAWAVEL PACK tlf aitalliefele)
°Aquifer Storage and Recovery °Salinity Barrier PROM TO . MATERIAL EMP7.AL` Nr METf1UD \
°Aquifer Test ElStormwatee Drainage ft. ft.
°Experimental Technology C i Subsidence Control ft. ft.
°Geothermnal(Closed Loop) Orlracer 0 n�TGQse:tpeb teems fiu�i-`-
O�at �f ootin Return) OC2rher .lain under#t!Remarks) FROM TO rise sole( dm emlrsick tree,arm i ewe_
Qi' -___-g f h ft, ft. 1
4:Date Well(e)Coctl3,lfted: te! "1 well ilk# -e. :
sa:Well l ttstaelo:a"s.
FaeilityiC/wnsr Naase Fw ility 1Dt# ' 1abie)
P
.�_
3C° I ft'_ TIt. �t,11���:-�3 1 t1
. _..201,E
ehyaicrI Ate,L'ity,end Zip ti I tt. ft. ._.-L7 ^nDe'"fi,
'4/'/1S ii OJT 7t ,'2K.Pg.. 31 s -. -, -
County Parcel Identification No.(PIN)
-
Sb.Latitude and loagltade hr1 degreee/minutea/eecsnds or decimal degrees: -_.1
(if well field,cete latik,atg is sufficient) 22.Certification:
Zi/ht --- WA- < W ,./ 1/ -' ,:e
<1,11.kbe2,45
6.Ig en)the w s):.r ent or OTeresporery 3ignetwe oft ertified Well Contractor Date
lty.signning this form,I hereby certify that the wets(s)ww(were)constructed in accordance with
7.Is this■runt!.to en existing well: : °Yea or fro 15,4 NNCAC 02C.0100 or 15A WCAC 02C.0100 Well Construction Standards and that a copy
Oki;it a reprsir,fill out knows well consyvction information and explain the nature of the of:kg"ear tt hat beet pmvided to the well owsicr.
repair under 021 rent.vle section or on the back of this farm. 23.Site diagram or additional u, dam:
8.For Geoprcbe1DFT or Cl -Loop Geothermal Wells having the same You may use the back of this page to provide additional well conauuct+on info
construction,oaly�OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'is Remarks Box):You may also attach additional pages if necessary.
drilled: �/J'A J 24.SUP3l0 1rfAI,INSTRUCTIONS
9.Toted well depth below lend surface: - of (ft.) Submit this GW-b within 30 daysof well completion r the following:
fi For na t4ole list ad depths if different(exannpie-3Q200'and IQ1001p g'
1@.Stalk utter level llelow 41i of 24a..For All Wells:-Original-form to Divisions=,of Water Resources (DWR),
P, '— : '- (ft') ;information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 - - ..
limiter kwi it above nitrite eve"+
J/� g, 'galWells
11 >terelsole diameter, 'F .), b.'For1(q�j®CtteD :Copyto DWR,Underground Injection Control(1�1�)i
..Program;'1636MSC,Raleigh,,NC 27699 163
)2^Well rift st.ROStIWd: ' ., C.. a l-,t~ :-24s.For Water Suprpllyy-and Oxen-Loop Geothermal Return Wells:Copy to the:
{i.e:auger;rotary;cable,*direct Pb.ui etc.)„ ` countyenvironmental beaith department,of the county whom installs
[FORwATSUwll1LSONLY: Wellsrelude over I0000.GPTIe Copy to DWR,CCPCAib. oat type: Amount:
Form OW-t North Caroline Department of Environmental Quality-Division of Water Resources I Revisal 6-6-2018