GW1--04426_Well Construction - GW1_20230710

1.W I Contralto Informatlo 17W//C A. eA/y /.'( 67i' 17 I \
WMIMConnactotName TO DFSCRIPirON
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NC Well Coanae or CettitiwtIon Number WItiOUTEit CASLYG'(fdit'mulliW d 4eIIT4j
R`-•litIt Bf' 'Ifigtblot_. ems; '
i FROM TO DIAMETERMAIjlf c W.4 ltmj $ere/ e 7, / a 7'll�
/J/J • • 1f iNNEkeAsidl' oma nIMor!(ie aiiacreaeddkraill m.T..., .2.Wel Construction Permit#: /36--
/ ! FROM TO MAM1"ratl TAICENESS SMATERIAL
Lftt ill L applicable nett earur uctianpendia p e.UIC•Cowry.Stare,Variance,etc.)- ft ft. In.
3.Well Use(check well use): rt. ft. I.
o.__...- ._.....-;sy.=.' `.vx_.•^-.:�41a:_ _2�, -eta
Water Supply Well: -gill'SEREEtz ~�- =-s—. :..._.:
FROM to °IAMET£R SLooTSIZE TUiCRNEsS= MATFar I. `
QAgricultural RMun-ipauPRblic 0 ft• R. io.
QGrathemtal(Beating/CoolingSupply) idential Water Supply(single) rt. m tn.
°Indust ial/Commcreia] QResideatial Water Supply(shared)
:73eQHoia':._.=: w<---_��..,,��:�:si.'st•'�:c•`-.4?`:"-`_'- �s;.`�•-+•-:;::�<-.tz,..,...
}Irrigation FROM TO MATERIAL , EMPLACEMENT:anion etAMoUNT
Non-Water Supply Wall: R m
a f kit n) ,41r'UC- PA.:Ve&inter
Monitoring Recov
d It. it.
Injection Well:
• _Aquifer Recharge QGmundwaterRemediation fr.
SAND/GRAvELpActmaeutteot le) =:7--7.`.•"-.s.- N =_ '
#3Aquifer Storage and Recovery QS3linityRealer FROM TO MATERIAL, EMPLACEMENT MrmOn
nAquifcrTest - 'QStormwaterDrainage n tr.
nRxperimentalTechnology CI Subsidence Control - rc tr. •
Geothermal(Closed Loop):. QTracer 10_DAIi:t INGIDG(uf6eli addlda liirefiieeritne'ca'aiijt -== *'_ < s_=:w
1Geothermel(Reating/CaoliiigRetura) J)Other(exQlnin under gel Remarks) 8Roh1 To oEscatrr N(color,hatdwr,to117 kApej van rcpetc)
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4.Date Well(s)Completed: 7✓ '-- Well mil.: it q0 n Gr e,....4.-e"7'e
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Sa.Well Laeatton; ('/� a j fr•
l ( �„y �G"�2avt G /G s/(C' n. y-r{ ., ._?.
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AailityiOrvnNaam ROW mE(if ipplicabb) re R. - - -- °^•`':.'o %,,
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• 0d ifAfi))-►4CJ J /6/G . )•-,-�3 4/ lz ft. itil 1 il ?1123
Physical Addeme,City,sad tip 2 IL •
Quay Pareelldenr,tieatiaa No.On4) Q•
• ' 7
Sir.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell daldaaattdlangiasnfficieaQ 22.Certification: • A.�j �f g- /�
2So 131.5iy� N F/CV/ a.O � W /� lit Pt!eliv '<- 7- ,2.)
6.Is(are)the well(s)0Permanent or ['Temporary Si&mnaeareenifed Well Contractor Date
By tiring Chit fares I hereby cerlly than the well(t)was(Mere)courtnured at accordance
e 7.Is this a repair to no elistlng well: piles or E14 with HJANCtC 02C.0100 or 1JA NCiC 02C.0200 Well Conrtnruloa Slander&and that a
(i:his is a repair,fill atalrraan well eentpaerioh kfannatran old crescent the nature of the copy ofrhu retntd hat beeuprotrdMAto thew('owner.
repair tinderI2l remark:sewn or on the hack Vas forar. .
23.Site diagram or additional well details: •
• 8.For Geoprobe(DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only 1 OW-1 is needed.Indicate TOTAL,NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
5 - SUBMITTALINSTRUCTIGLS1 •
9.Total well depth below land surfacer (h•) 24a. Far All Wells. Submit this form within 30 days of completion of wall
For muGrph;weir(wail daprlu,Jdfjerent(tsmnple..1V00•and @100) construction to the following •
10.Static water levet below top of min: 6 (ft
"wore?latel tt above wag use+ ) Division of Water Resources,Information Processlug Unit,
1617 Mail Service Cehter,Raleigh,NC 27699-1617
11.Borehole diameter: l0 /..1 (In.)
t (� (- 24h.For Inleellon Yells: In addition to sending the fann4o the address in 24a
12.Well construction method: /QG)�A r 1 ( - above,also submit one copy of this ibrm within 30 days of completion of well
(La.ago rotary.cable.Cued push.era)) li construction to tl¢following
FQR WATER SUPPLY WELLS ONLY; Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699.1636
t pp /
13a.Yield(gpm) . •O Method of test. f.f)t�'(3l4- 24e.For Water Sunnly&Inleetton Wells: in addition to sending the form to
/� (' the address(es) above,also submit one copy of this form within 30 days of
13b.Disinfection.type: i �f Amount: - Co,'} completion of wall construction to the county health department of the county
where constructed.
FomsGW-1 North CuolionDepartwat&Tarim:mama!Quality-Divisio oaf Water Resources Reviaod2-22-2016'