GW1-2023-02979_Well Construction - GW1_20230425

WELL CONST _�_...•_._. ._.__.•_. _ ____..
RUCTIOI�I R +CORD GW -.••.-
'L Well Contractor information: 1 For Irate
mat Use Only: ;+4. �111t�F011
Well Contractor Name B ��
WATER'ZUNE$".a,•7O Dft
ESCn1PTION =AS'•S' ci 1•i ..:y"';.sii•
U Contractor Certification Number ft
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D
!✓✓• 0 G IL 113iOUTER
Company Name FROM for.niOtfiasbii we1l�
2•Well CO DrAMETER a ii¢shle i h ;(i>••' r
U ft THICIQIpgg MATER� r;'r.`.i.;,,'
Construction Permit#: / g in z �~
List all applicable the/l co "16�'
• rtstructlon p '��R CASING OR ermlts(�a UIC,County, FROM TI)Bnvr
3•Well "FSttie yt
Stare,lrallonce,el TD D i6ial:cluyed-loo' e;.•t ;•n,;,,.,
Use(check well use): �� ft ft.
METER THICRNFSg " '�'• `�''�<��;�;,y::'s;t
in. M'�TtAL
Water Supply Well. MAgricultural ;l�;.s ft. �•
CREEN`al'+- Y`lfi u-: a;.rsg
Geothermal(Heating813QCiPal/Public FRoM • lkly 4'C3 i>�',:ti ?I^ .,
/C00 Mg Supply) Residential Water 0 tt D ►PETER starslzef: TAI" ;,}7:
Indust ial/Commercial S°PPIy(single) ctav mtATEnrA1,
Irri anon E}Residential Water Su M ft
Non pPlY.l#hd) !a
-Water Su C� '°`� ?. 11s GR0 ;� :.•:.• r,
PP1Y Well: UT'.':�;,;1•,.,,.;..,�s,,;.
Monito
ring ction �t 1� � MATEnIAL' •is!:. •yf.>..:��:y�4�.+¢^ii�it- ir liir,;;:!,'f.
Inje W ell: QRecove d R ��MTh1ETROD
Aquifer Recharge I kM
ft.
Aquifer ]Groundwater g�,„��
Storage and Recovery n-F�f eEi ►Cn'►9 Un' ft.
Aquifer Test iQt r°�t� ''19:3AND/GRAVEL ft
Pe me e:JStormwate D FROM PACT{ffa Lce61e'::s;j;>"' ;!; .•
Ci ntalTechnology r ramage MA1Elt1gL :'°`; p;4?i}i;.ct...;..;:�;
Subsidence Control ft.Geothermal(Closed Loop) Et►recnceMENrMETaoD
'Geothermal '
OTMcer ft.eating/C ool 4 in Return Other( lain under#21 Remarks) of OG airbcfi"ilu.ldiial'aheets;f ,
.Date Wells)Completed:
Sa.Well Loca Z ell ID# ecess
tt, J 3 D�C 'RrP7ION eulor r,,, �,�tu,oc4
tion: m 4
l3 �
rJ/,n U/ �er•S'ed•,
Faac,4ty/p er Namo 6 E ' e
/�D P bier Facility ID# ifs S
IL 01M.
(11 r PPGcable)
Physical Ad a li t71
��,City,and Zip �! Z a � ft ` &
C. 6 &eft
$b�tY Parcel id 68H I21.?REMARI44 i.xo+,+;r;'',.:\l;tiii;�°{�:!•::.tt+.;:,�,.. .-.
.Latitude a eatifi oa No.(PIN) �+ �— 9,
d :.n r,';�i'),;::,tr•C;i 1Y'.S' s��:.,,,,t and longitude io degrees/minutes/seconds or decimal degrees:
(dwell field,one latAOng is sufficient)
N �j/, / 7 G y 22•Certification:
6.Is(are).the well s 9� �' jJv G, i
O ermanent or
Temporary -
7.Is this a repair to an � Si ifs ofCemfie' Weu Contractor -�
#'thls is a re air, existing well: 13yes or L:G, •• Dato
P fill out know„well construction tnjortnotl0n y slf-ing lhls AM I hereby repair under#2/remarks sectl0n or on and tvllh lSANCAC OIC0I00 orr jSrt fy that the tvell(sJ twos(were the back ofthls jotti,a �Plaln the nature ojthe copy ofth�Mardi;bed A NCAC 02C.0200 �camftcled ut accordance
8.For Provided to the the//ovne�e!lConstrrtctlon Slandardr and that a
Gi o, o only
I G or Closed 23.Site din
construction, y 1 is needed. P Geothermal Wellshaving the same You may green or additional well details:
drilled: n,oral 1 GW_ Indicate TOTAL, Y use the back oft his
NUMBER ofwells construction details. Page to Provide additional
9.Total well depth below land surface: You may also attach additional well site details or well
Formuplple tve!/s/Istalldepthr yd�erent S�MITTAL INSTRU Peres rfnecessary.
(example 3 (ft) _TIC UNS
10.Static @200 ond2(¢3100� 2'la• for 11 ells:water level below to �'� &owi Submit tins foram within 30 days of completion of well
/10,S r level!s above casing,rare..top CBSing. ,j 0 construction to
(ft) Division of Water Resources
11.Borehole diameter: 6 XL, ,Information Processing(in.) 1617 Mai!Service Center,Ralei g Unit,
12.Well construction method: o�/rto 24b-For Injection Weps, gh,NC27699-1617
(i.e.auger.rotary,cablq directpusk eta•) above,also submit one co addition to sending the form to construction to the following of this form within 30 the address in 24a
FOR WATER SUPPLY WELLS ONLY: days of completion of well
�i Division of Water Resources,Underground Igectlou Control Program
13a.Yield(gpm) /,�
Method of test.
'� 1636 Mati Service Center,hale h
13b.Disinfection �r 24c• or Water SunOly& ig ,NC 27699.1636
type: �'h Amount:• cJ the address Injection Wells: In addition to sending completion of) Ove,so submit one co of rm g the form to
construction to the count' f0 within 30 days of
'arm GW-I where constructed h'health department of the North Carolina Deparhncat ofEnviroamental Q county
utility-Division Of Water ater Resources
Revised 2-22 2016