GW1--04338_Well Construction - GW1_20230707

i.I. ,,CAN UC'1'ION RECORD(GW-1l For Internal Use Only:
1.Well Castracler IInform oia:
Well Cmnsactw Name FROM TO DrSC 13aPTriritl
ft. R.
a 13 rt. n.
NC Well Coatmcter Cati&calion Number �—
10, . CASING mold )91ILIERElit,<' )
Company Name
e567 3 -D°-3 � TO d� DIAM DIAMETER = TRIMNESS MATQBIAL.
2.even Constrncdten Pursuit#:
Lizt all appi cabk well construction permits(i.e.UIC,County,State,Variance,etc.) tt. f° M.
3.Well Use(cheek well use): ft. it. In.
Water Supply Well: i -1�
1 F3Z0146 TO + Malt au THICHNISS MATERIAL .
•Agricultural 0Municipal/Public it. it. le
I Geothermal(Aetating/Cooling Supply) _'''esidential Water Supply(single) n, St. in. I
A.Indactrial/Conimcrcial $Residential Water Supply(shared) 1&GllOV .
aline_, :tto WHOM TO MATERIAL EMPLACEMENT METHOD£AMOUNT
Non-Water Supply Well: ,1 tt' ac2 it° �• 2231t..
Mill Monitetg liailitecovery _ ft. ft.
ft.
te.
Iir Aquifer Recharge °Groundwater Remediation
19.841111/GRAVLL PARR OE altaltahhe
'$' '.uifer Storage and Recovery Salinity Barrier &ROM TO MATERIAL EMPLACEMENT METHOD_
*Aquifer Aquifer Test DStormwater Drainage tL ft.
.*EsperimentaI Technology )Subsidence Control ft. ft. .
R:Geothermal(Closed Loop) °Tracer DEILLING LOG mach additictvsat siee@a if atso9toarj
E:Geothermal ., oolin:Return Other -4,,lain under tr 1 Remarks FROM To DESCRIPTION(Men taar�aasy seturnek type,ants et r,
ft. ft.
4.Date Wells)Cn :c /1 7/MAt 4 Well ID# N° fe
Se Well n:
Facility/swam Name Facility'De(if applicable) le ft.
Lei✓: 62i-t. ie4 ft. ft Jtit 0 7 2023
Phyniccall Addroiea,City,and Zip 'y c t. C� r It. !L :eel. ?:r cf��`,? U r.t
Lai f if�J /✓/ (] 3t7 y tnl✓�7,*: na `t;e :.�
43
County Parcel Identi&c etine No.(P
Sb.Latitude and longitude in degrees/ndnutes/seconds or decimal degrees:
(d well field cat let/long is sufficient) 22.Cettkiir tion:
ildit N je,
or
w i'- ,„,.."-z. _1 4 4 • 44.5-1,x19.,,,i
6.Is(are)the wellsermnment or OTe rary Signature of Certified Welt Con. Date
rr By signing this fern,I hereby cent y that the well()was(were)constructed in acconiance
7.Is this a repair to an existing well: Dyes of No with 15A NCAC 02C 0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
Phis is a repair,Jilt out brown well construction information explain the nature of the COW elks record has been provided to the well oxmer.
repair wider#21 remarks section or on the back of this form.
23.Site diagrams or additional well details;
8.For Gesproba/DPT or Closed-Loop Geothermal Wells baying the same You may use the back of this page to provide additional well site details or well
construction,oily 1 c/ is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ////
,6UllVu'I"!l'a INUC°TION5
9.Total w depth below land surface: at,) 24a.For All Vleps: Submit this form within 30 days of completion of well
For multiple wells Just ail&eodal rdifferart(example-3(a 200'and 2@l00' construction to the following:
10.Stack water level below top of rasing: --- (ft.) Division of Water Resources,Information Processing Unit,
.lj WCA:7 level is above casing.use"+•, 1617 Mail Service Center,
(. �� Raleigh,NC 27699-1617
11. (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well ea mod, above,also submit one copy of this form within 30 days of completion of well
(lie.auger,rotary.table,direct push,etc.)
construction to the following:
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpae) / O Method of test: l/ IJ>47ip- 24e.For Water Sum&!&In.fettIon Welke In addition to sending the form to
} the address(es) above, also.submit;one copy of this form within 30 days of
13b.Yt nfeedon type: aI f,k9 Amount: _ completion of well canstniction to the county health department of the county
where constructed.
Fcnm OW-1 North Carolina Depart:numt of Environmental Quality-Division of V/aver P.eoureees Revised 2-22-2016