GW1--03166_Well Construction - GW1_20230505

IMMILIQU-110N RECORD(GW-11
For Internal Use Only:
1.Well Contractor 1pformation:
Well Contractor Namne
FROM
.S
4f
ON
A
1',eI Nun it.
ie We, D
COMpan TE
yName ft.
2.Well Construction Permit#. Pa(q� FROM
Lkt all applicable ft cable well construction (he. colmumnty, Tfu S MATERLAL
3.Well Use(check well use). it.
p I,a I III:r11i applyg it
-VO-CM,
PROM ro SLLO
coling Supply)
tkesidenffal Water Supply(single) • fL In,
C31ndustrial/CornmereW OResidendal Water st"ly and)
(Shared)
r4on-Wate Supply Well: 13WOlts>100 000 GPD Mom TO A C 110D&1 fir-OUNT
13NIonitoring 011ecovery 0 ft- en. h
Injection f4 it.
MAquifer Recharge E30roundwater Remedied
OAquifer Test t- -�2� m
OStormwaterDminage 44 its2D
0EXPcdnI Technology OSubsidence Control ft.
[]Geothermal(Closed Loop) OTracer
DGeothermal(Heating(I ESCRVnca lllpi
ReI 132Lh�explain under*21 Remarks FROM TO D
aoNtnek eta
4.Date Well(s)Completed: Well Jim
So.Well Location:
lob
d! rej A j
Nam Facility M#(if appacqle) ft.
Po It it " m ft %
Address,City.and Zip . I-
Physical ft. ft. CA
I..................... r'OG
County Parcel Identificatlo No.(PIN)
5b.LaWnde and lanaitnde in deprep-4/mi"nteshlechmiq or d".1m I therm...
(if One orf L017-a Ii.vlir-
22.
00-
6.Is(are)the well(s): 4em"ent or OTemporary SJPn1tMof d4UCctor -TIV Date
7.Is this a repair to an existing well:
13Yes or [ o By signing this,om 1here6y cer*that the W11(a)was(were)constructed in accordance with
repair under explain the nature ofthe ofthb record has been provided to the well owner. Cowftcgon Mandardr and that a copy
Ifthis is a rVairflil out known wei?construction hiformation and 154 NCAC 02C.0100 or 15A NC-4C 02C.0200 Wefl
-42J remarks or on the back ofthis form.
r 23.Site diagram or additional well detffil
n
construction,only I GW-1 is needed. lndica-tz'T
'!
OTAL NUMBER ofWells (add'See Over,in Remarb B el=tn-
drilied; 0)4.You may also attach additional pages ifnecessary.
24.SUBMITTAL INSTRUCTIONS
9.T
.Total Well depth below land surface-
For mur*lc w-*Ik list all depths jfdiffermt
10-3 and 2@--1005 Submit this GW-1 VII 30 days of well completion per the following..
10-Static water level below top of casing: 24a. For All Wells.- Original
rwater level is above casing,use form to Division of Water Resources (DWR),
(it InicI Processing Unit 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 24b.Eo
(in.) 0 For Injection Wells: Cmv tn num Tr a.... . ,2 T_!_
12.Well construction method* A ir 1r6-kV-;.
(Le.auger,rotary,cable,direct push,etc.) 24c.For Water So and I
-- - P1 _Aen-LooWoeathermal Return Wells-Copy to the
county envft6mne-nj@j-"Md
FOR WATER SUPPLY WELLS ONLY: apartment 07MC-C-OM—t3 installed
24d.For Water uclu over
it*WZr Wells rod ear 100,000_GPD3 COPY to DWP,CCPCUA
16r_
SC gr
Program.16 1 S , ei C 276 9-1611
C 2767 9!IG
13a.Yield(gpm) Method of test: Lbw 611
13b.Didnfaction type: 4-k t6
Amount.•
FMMGW-i North Carolina Department of Em*onmental Quality-Division of Water Resources