GW1--03979_Well Construction - GW1_20230612

1.W 1 COnlract0 Ilttormat 0 a ZTt%•'1, C_V'
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• WedConnallorName ;MOM TO OFSCRICrION
6`eV it: 7(0 ft• Z ' 0 G�.A=t,
NC Wed coon or Certification Number
,A MI6.dUTERVASLYCi'(t6lriaidli iist3Villi. MER N-'litib►bk•2 :•.: ?�:
taeeirc f.1.h�-1(aY?,c4 1'"( �eruir mat TO DIAMETERuL111100rES$ MATERIAL
Ca f ‘. ' i siDR-12 P'vc
1 IVNISR(CASIrYItIOICTbAihf(i(tftulhTrtiul:clviedloop).�•u•+s:�t �c.�._
2.Well Construction Permit Si FROM TO COMER ; 17L/E104169 MATERIAL
lfitAuapplimbremellemuwerionpenntpp..UIC•Chery.SUM,Variance,etc)- tr. tr. lo.
3.Well Use(cheek well use): n. tr tie.
Water Supply Wen:
'an'ifllEI3l`tit — - .: ,1 T _� _ -___ • •
_ eter Agricultural FROM TO �DIAMETERSLOTSIZC THICKNESS —MATERIAL=`
tcipaliPablic 0 rt• rt. in.
Geetherntal(Reating(Cooling Supply) idential Water Supply(single) et. tit: to. -
_Industrial(Commcreidl _ DResidentiat Water Supply Oared) ._._._
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._Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&A1IOUNT-
Non-Water Supply Well 0m rL
Monitoring [f RecoveryO !A) l���— �'•i+rr� i1lL .
tr. rt.
Injection Well: .
fr. R
• _ Aquifer Recharge [lGmundwnterRemediation
.3S.•19.b ri/GRSBLPtCKBfttncmEabte)?_ r. ••,,-' ,� ; _AqUtfer$torage and Recovery ry ['Salinity FROM TO MATERIAL, EM141CiHErmrrn0n_Aquifer Test - -DStormwater Drainage n• m
Experimental Technology DSubsidence Control a. h•
• .Geothermal(ClosedLaop);. DTracer - `sO:nRItlaN(ilsjGliifadiiadlliw,eiiteiliWic-isiirli)'='__ �-t ^ u .
_Geode:noel(Amting(CoOliogRelent) IOher(explain under/el Remarks) liRdObt it TO R. DfSC`H/IPTtpY(mlor,hndntu,wlYrodtl)po�etfFnncaetcf
4.Date Well(s)Completed. /� � WetllDfl„ tea, & 7G tL /` '4.-1 Clams
Sa.Well Location: 70 a CS It: 6,re,, e,' /7;z:r, is `a
0 S`,41!l a4G/f/4. /�1c?2 0 ft. ft. ,.."•�,+ IV a--..
PacilitylOwnerName /h/ Faciitymit(ifipplica1a) h. ft. Jl,N 1 2 ?073
00 iiCW li/ d l.// 6:1442.a Q o..5 fr. ft.
Physical Address,City,sad ripa n. tnit.tcrkNrc--t ref. ".. mi t.11;
• _._..nr,,__._.ic_h:.:r.•rt Y.�I.:r: N../. µ+r--.mow.
County Road Identification No.(PIN)
Sb.Latitude and longitude in degrees/mlauteslsecoads or decimal degrees:
(ifwell field.one tadlong is sufficient) O S 2.2.CertificaiioO: A,, gf g- a
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3s 1<< Z� ?o N V1/ � �3o
6.Is(are)the well(s) w nqe, )22441-9i- PW.16,1 c- c---22
WPermnnent or QTemporary 9igmtmeo emfled Well Conascror Dale
By tiring this Jon;I hereby eerlgy than the trell(s)ioar(here)co severed in accordance
e 7.Is this a repair to an existing wets Dyes or.CO: with 1SANCAC 02C.01OO or 111 NOW 02C.0200 Well ConnnicilonStandar&and char a
fads isa repair,fill osu imam wdreon uwianhfmnmmnanderplainihenmureofihe COOffhI5l5co7jJt4j been pro Wded(o the iveU owner.
repair under ON remarks section Man the backof thrrfomr. .
23.Site diagram or additional well details:
• 8.For GeoprobeiDPT or Closed•Loop Geothermal Wells having the some You may use the back of this page to provide additional all site details or well
construction,only I GW l is needed.Indicate TOTAL NUMBHR of wells construction details, You may also attach additional pages if necessary.
drilled:
C ,Rl7IInII'rTAL INSTRUCrIQ Yam$
9. well depth below land ssurface: (n•) 24a. For All Wells: Submit this form within 30 days of completion of well
Formurmu(Ulapfe wens lorandyulu fdl•Qerenr(ecatnple•4200•and2g/01F) •
�� construction to the following:
10.Static water level below top of casing: (It.) Division of Water Resources,Information ProcessingMg
filmier tr above uum&use"+" 1617,�fail Service Center,Raleigh,NC 27699-117
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11.Borehole diameter: /
/44 (In.) 246.for Inlection Wells: In addition to sending the tana•to the address in 24a
12.Well construction method: JQO'(0.r I ( - above,also submit one copy of this Ann within 30 days of completion of well
(in.auger•rainy.cable,day push,ere.) e// construction to the following
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program.
� 1636 Mad Service Center,Raleigh,NC 276991636
13a.Yield(Spin) a 6 Method of test: I '(}t— 1D it h 2da.For Water Sunuly&Inlet don Wells; In addition to sending the form to
I /i the address(m)above, also submit one copy of this form within 30 days of
13b.Distnfecdan type; 17 !e Amount. '-' completion of well construction to the comity health department of the county
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- whore Cons4UCted.
FormGW-1 North Coati=Depurmeat afFsoimaraeaml Quality-Division of Wet Resources Revised 2.22 2016-
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