GW1--03845_Well Construction - GW1_20230609

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nuismimu, ilic_attUg/BPAL3V_V-1) For internal Use Only:
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1.Wall Contractor inforniatIon:
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FROM ro 1 0180117TION
Well Contractor Nam ft. ft.
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Well Contractor Certification Number
N'AIMPAR C..'3 6 '' ''''' ''''`c.'' . ''' •-__....."'`?;.....,' .4:L4' '.,_... nti,4.11.4.:''k:
e ? i e MOM 1:i/TO .2 0 r!1 i,.,1 1 `I Aims up 44.4(2$110f1:51111. MA,p4,....j.
TNAII2111/7X111' r PrIef=11111
Company Nome
2.Well Construction Permit s: A-I).-,71nict mom 'Lim= DIARIZTIO1— THIC1048i ISTATTIRPAL_
.U.st di applkaahie wail conitreection permits(Le.UIC.County,S2, Variance,etc.)
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3.Well Uae(cheek weft .we):
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Water Supply Weil:0AgrismItand omunicipaypublic naor9Mn4ist 11J 1 MAMMA SLOT SSZIL 1MC1011189 MATERIAL
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°Geothermal(Heating/Cooling Supply) ,eiltetitiential Water Supply(single) ft.1 ft. Lo.
0 indasnial/Cormnercial °Reridendel Water Supply(shared) ita494),/, Ili
Oltri ea °Wells>100;000 GPD 1 mat TO
_MATILRIAL , _ 111315.1ACEMENT14121110D&AMOUNT
N.smeNvisiter Supply Wen: el ft. "4,i 1 ft. a' 4:le -4,64)1
4,
0Mccitawirt Mammy •...- ft. :: it.
hiesttion : ft. .. It I. • .OAquifer Recharge °Groundwater Remediation ' ...,,
11 0/10110211AWSL MCI&01 trothellar0 •
OAquifer Storage and Recovery °Salinity Barrier 119110/0 TO MATEUAL I IZIPLACIAOLNT METHOD ----
OAquifee Test OStonsiwater Drainage ft. ft.
cm,valmvatal Technology OSubeidencecoutrol: -. . e :, , ,•ft. . • ,. T .Ft... ,: .:
°Geothermal(Closed Loop) °Tracer 20.PRILI..ri r. i, _fpttesh eargdowil slkselsff wean*
EiGeotherinal eati 'opting Return) 00ther(explain Under#21 Retnarks).- 812082 DE2C2IFTION(ottor,hardans,oaltireek ewe,vex lank(ea.)
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1.j212pli
.i 4.fka4 Wellitt)Cottigalcd: g •.Well Miri '• - : ft. ft.
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PsOilityielia*NoMe;,._..,:.,.-,j i . .:„., ----- -, i ..•:-..' f satiny ID#(if applicable) : • ,'.,'!,.-,•:,:.-.,:..f.. ..„.':: .• ......:. :;:ki• -',...,,f...ii :;-i,.-10,..,;.,1-...t3-'• .: ee.
Litf(;:ailyll...issUatY, irjr_ia.R..e._, ''.-'••,-''.‘,-,11.7'.•:h710
Physical A eras City,in0 Zip ''-, : ...:,..:.; .,:.:L%I%1.,f,...--i--• . Iii- :::'-'-': -,'''.)..:;'-', . ''-''-:J.1-',-, ,'-', ':., .Y,'',.!'=-: ...1" :: ''' :',:,',..:.J.
a i , • -. .7 . e ;-;•C'::-:A7--:4;1 PIT'7,74-entrt -
-ALi i4 ' - ' - ' ---r":' :' ' '.75'71.z.. 21 1
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County Patel titentificstion No.(PIN)
Sb.Latitude and longitude in degreethreinntesiskonds or devimel degrees:
(if won&Id,one al ia sufficient) 22.Certifs.:radon:
2o
W
1 of Certided Well ontroctor Eva
6.*are)the well(s):Japernannent or OTemporary
( By signing thieform,I hereby oar*that the sniffs)was(Imre)constructed in 4C0011441100 with
7.Is this a reps&in an Wading well: OYes or IkNo I SA NC4C 02C.0100 or ISA NC4C 02C.0200 Weil Construction Standards and that a copy
USA&is a napair,,fill old brown well construction information and wroth the nature of the of thls record has beef provided to the weli Dreier. i
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repair ear hi21 revereb stellar or on the back of this form.
23.Site diagram or additional well OttliI8:
S.For Geoprobe/DFF or Closed-Loop Geothermal Wells having the same You rnay_use the back of this Page to provide additional well constmetion info
consttuetion,only 1 çw.i is needed. indicate TOTAL NUMBER of wells (add'Set Over'in Remarks Box).You may also attach additional pages if neetraiary.
drilled __
24.SUBMITFAL,INSTRUCTIONS
9,Total well depth below hued surface: = Ze 0 MO
For maple wells list all depths ff different(=ample-3 00'ond 2®100') Submit this GW-1 within 30 days of well completion per the following:
, : , ,, ,, .,,,, 24a. For AO Wells: Original form to Disision off Water Resources (DWR)
ruler leer Is above casing,use
lit Static'Age .Lvitel liaidiv tOP Of aiding: V.....e...-V,...— ,' ti , ,Information Proctesing Unit;1617 MSC'Raleigh,NC 27699=,617
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ii ja,it.e.40:44 diameter::::,,.4,, ..4...„.,., .::on.) .,:,:,, , „ , , - _ ,24b. For loleation Wells:Copy to DWR,Underground Injection Control(Ilic)
,,. :, -:._ ,, ., •e, - 1 • ‘.r. '...Program..1636 MSC.Raleigh,NC 2760-1636
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-12.Wall eatisteletki. a Method: ea big._ , ..„. , :
, . , ,,, . ,,,2,1c.For Weottyt ante ypen-Leep Geothermal Return Wells:Copy to the;_ .
'On;c*ir.ieraiy.cable;ths,seepuen;.ate.) .- -
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$1,1 WATER SUPPLY WELLS 01411.,Y: 24d.ForValei VtallifiPiiieliteltiiiiC,RaleighNC 699
Ver 144)004 GPECCOPii.OITiWR.;eati.):
', rmPograna,1611 MS . 27 -161 , ,,.. . —..
13:s.Mid .-• ' ' :Method:of test: ' 'PO n7 Peit„ r
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13b.Dirintbellou type: c;-rri2r7 ' Amnon
Form OW-1 - North C,siolina Oupts. Ict of Eovlsvninonta1 Queury,ntvistan or Wei=Resources Revised 6-6-2018