GW1--04352_Well Construction - GW1_20230707

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.WW Cont raetar Information:
e....404 e-/"A le/ Si._56'e-i -, e------ :,t4i W*1142:00.2*
Well C cmorx me Fib ?o tic a>r atilt
fir}• �. f�
Nmiell Contractor Certification x, �2 l
� FROM 1'O DIAl16Y� : -T<'QG�148 •�{� l+ tAG
/�5 e e..5 /1iJi r 1 n 6-- �--7111144116 �.
Company NNW Sii<iQtn . tl .'_ _..
2.Well Conduction Permit 0: P -46/55 9 ARM il► Rnu.
LEO all oppllcable mull ooartiuetlo,,permits(Le.UIC,County,State,Variance,etc.) -
3.Wail Use(check well use):Water Supply We11:
ft. ft. <s.
VAMP
FROM TO 1 Da snit k relit Tiofte asttgsta
* •,'cultural DMunicipal/Public ft. it. is
f Geothermal(Heating/Cooling Supply) esidcntiai Water Supply(single) ft. tt, at
a I ial/Cammescial D esidential Water Supply(shared) , .lei m -
■Irrigation i' OM TO A ' ciATIMIAL FMPLACOMMT METHOD a AMOUNT
Nea-Water Dimply Weil: ? C ��?A _ - -
•Mooitonn j Recovery / ft. ��aei*zt`
Weil:
ft. flu.
ll'AquiifierRecharge DGrotmdwaterRemediation -
ii•Aquifer Storage end Recovery Salinity Harrier PROM TO reAltRIAL ,p NT=ROD
II Aquifer Teat • - DStormwater Drainage rt. f-
■Experimental Technology DSubsidence Control - 0. . .fe• .
.a c_ . (Closed Loop) OTracer ' S.DNiL1 LOc- 0—Fresh atifitiestel setrOlit ifie0001sSet
NI Geothermal(Heating/Cooling Return) .inOther(explain under#21 Remarks): PROM (motor 6arirsr sdyrmek tstte,oaa ctn.te
it.
.1.1lteto'Wet!(®)Cempletbed:403/ ..763 Wen 1139 ft. ft.
Sa.Wedl l oeatloee
jG.SSI`[d Uavvi.i«A
Facility/Owmr Nave., .:...• ,
Facility IIJ*{if applicable
Alle `/( eA. / - 4 c.x .r .1e 11 9 ?�i 2023
Physiti�l City:sad Zqr -1 .:..
fir- 4 S t s/ 7i34 l 7A)1 1 t�5^c� t Y'1 F '�.:a f Sr, -.
�Y Parcel Ideaditcatio®xo.(PILL) '
Sb.Latitude and longitude in degre miminutes/eeconde or decimal degrees: .
(if well&Id,me e is eufficieat) 22.Certification:-' , - '
./41/..A.- N .../a4 W : : ,
6-le(are)the weld(olErPermanent or T Sig of/ n D,�t� � �
e r'ary
) • By Aping this fors,/.hereby c etlyy that the se l(s)was(war)ccastructad in accordance
7.Is tide a repair to an existing well: DYes or o with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
ticks is a repay,fill out btbwiv wall contraction information B lain the nature of the MO'of this record has been provided to the non o ran r.
reparr under#21 remark or on the back of this form. 23.She diagram or additional well details:
S.For Geopre he/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction, yr,}A-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: Al
§VTAIMITTAL Ir UCJONS
9-Total wail dtgtA below lead surface: Q • (ft.). ;24a- FrAil Weh. Submit this s farm within 30 da� of con letion of well.Pcra!!'1. 10'' 1 1od49:,1(fd _(awmple-3W90'md 1©100') .. consttk¢nontoUe.followmg .:. . . .- . - . . .19 Stadx'water level below top'of casing. 0b '
(ft) ::- Dtvidon of-Water Ftesa =lnfercaation'P'ry _FTnit;. '.
{/saws law_!te obane caret&use'+ ce9-16
1 _ _ -_... _. �� � 1319 Mail 9ervlee Cer�ber,RaieRgb,1VC 27699-1ti17 .... ..,,
11.Betrelole sr (; '% (hi) 24b, or`Inlee tton WeU ,In atkittion.to,. ei sanding the.form to the-address in.24a,
12.Well etaartxt4tctbe method: � ;above,also
submit one ropy of this form within 30 days of completionof well
(i e`strgec rofirsy,sable,direct. emc.) .
+constn�ion to'the following.
''Division of Water Rewtircea;Underground Injection Control Progra
FOR WATER SUPPLY.WELLS ONLY - - 1636 Mail Service Center,Raleigh,NC 29699-1636 -
m 13a.Yield(gp ) `' ) Method of test: I 24c.For Water'Suooly&linlect#oo Wedh: In addition to sending the form to
the addresa(es) above, also submit one copy of this form within 30 days of
136.Disinfectiin type: Amount: 1- - completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Deperhmnt of Environmental Quality-Division of Water Resources
Revised 2-224.016