GW1--04530_Well Construction - GW1_20230713

I.W I Cootracto It:formatloly, I • I
WellContracrorwame •• BROM TO DESCRIPTION
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NC W U Contras orCertification Number /, ':;{3.ORIERC]1SLNti'(fttiKmollire eta weIIstGIt1;1NERV[(l:a..hlatdel�•�r. :'t:.•A!e:
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To DIAMETER TrnQL�rPss MATERIAL
/ / /' 16a NNERCASINt OR'tUDING:( therrual:tYosed:t"ep).••F„a++.err.w.A :•
2.Welt Constraction Permit#: / / 6 FROM TO DrAMCfEn TIUCIOiFS9 MATERIAL
Lfsratlapplimbrewdlcaw:ructionpemdu(te.U1C,Coanty,Stare,Variance,era)" ft h. In.
3.Well Use(cheekwell use): R. fr. In.
Wiser Supply Welkri2:SSREENt . _.v__ -_ - •_ .R: � - • .
FROM TO DIAMgra:a SLOTStZc •TIiICMN ESS -•MATFAUL-
DAgrieuitnral , DM icipel/Public 0 h• rt. in. -
}Geothermal(Heating/Cooling Supply) idential Water supply(single) R. m is "
[._}IndustriaWCommcreial DResidential Water Supply(shared)
Irrigation PROM TO MATERIAL , LLMPIACFStENrM1THOD&AMOUNT•
Non-Water Supply Welk C n' ,5- rt. N iv `r1Jc s p6.wed_OIL.
DMonitoring ❑Recovery • R. ' .
Injection Well: R. .
• 0 Aquifer Rechergo riGmundwtterRemediation It. h.
DAquifcrStptage and Recovery DShcinilyRerner '.] A2tD1GRAstSI:PACKMATEfiR)f - -:k . E;: r; .
Qs1 iferStor EMPtAatuttaramnion
qu 'DStotmwater Drainage f tt
�ExperimentalTechnology DSubsidenceControl ft. h.
Geothermal(Closed Loop):: DTraeer z30:1311 4.. OG�iiiueli iddlticltiifaheiliTtttecaaitKf ,:t'. "�= : •
Geathumal(lleatinglCotill4Renttn) 0 Other tsRlaii under 0Y21Remarks) 0u 1 TO DFSCa1Pft[JY(ulor,6asdnn,,selptatpl�wjxnfn�ce,eu)
a' G o " f1'z"c,/���y
9.Date Well(s)Completede� o2 2 Well Mil �G 17�s h• 6--c '.r e- --e
5a Well Location: 7$ �G S.tr. < per,.PJ`�
G C/O4/' 17 /��,�-� h. n.
Faciiiy1OwnerWane y� Fecilitylna(if appticable re R ,. '7. .!
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Physical ABdttsss,City,sad Tip - it. ft. 1
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County PnreelldeatiSeatiaaNa(P1N) .___.__._..-- ini'Ji.,...:"�� ';2, Ur;i:
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56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: )�
Orwell
ld.one letMng is sufficient) 22.Certification: V Cf ` 17
. X. 3-5. 4 9 2.)0 N V6/_3),- r a w ‘
6.Is(are)Ihewelt(s) Permaaeat or )Temporary Signatureon ( JQ7.
0��� .
oifiedWeIICoaautor Dale
By tigni lg lids form.1 hereby certify drar the trell(s)urrr Oren)cottsatnred,b accordance
a 7.Is Ibis a repair to an existing well: Dies or with 1JANCAC 02C.0100 or 1JA NCAC 02C.0200 Well Coasrnwton Standards and that a
((this rs a repair j1ll old inoMtwdt cam rn,crioahtformatian aid esplam:he nature ofihe COPY edits"mid has bteaptoWddd to them"owner•
repair under VI remerkrseuioaoronthe bark ofrhtrform. .
23.Site diagram or additional well details:
• 8.For Geoprobe/DPT or ClosedLoop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only I GW 1 is needed. Indicate TOTAL.NUMHlR of walls construction details. You may also attach additional pages if accessary.
drilled:
Gs ,STII1M1TTAx.INSrR1ICI19N4 •
9.Total well depth below land snthee: (h) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wdk list all&pits Ildyfesenr(eromple.4200'oud 20100.) construction to the followin • •
10.Stat[c water level below top ofcasing: 3 (It) Division of Water Resources,Information ProcessingUnit lfwarerl eelftaboveeasingwe+" ,
- / idn;fait Service Center,Raleigh,NC 27699-1617
1 •
1.Borehole diameter. W 1/ / (In.)
L 24b.For inlecllon Wells: in addition tosendntg the tannto the address in 29a
32.Well construction method: P O r lam( - above,also submit one copy of this form within 30 days of completion of well
(i.e.ammissy,cable.ducat push.etc.) �/ff - construction to the following .
c.
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FOR WATER SUPPLY HELLS OW: 1636
of Water Resources,Underground Injection Control Program,
1636 Mail Service Ct alai,Raleigh,NC 276991636
13o.Yield(gpm) 5 Method of teat II if 4:lrJ'..p 24c.For Water Sunnlv&Infection Wells; In addition to sending the form to
/� the addresses) above, also submit one copy of this farm within 30 days of
• 131t.Distnfcetlon type: t11 Fr Amount Cc- completion of well construction to the county health department of the county
where constructed.
Fenn0W-1 North CcuarimaDepartaieer orEetvitemneetal Quality-Division of Water Rcaemses Revised 2-22-2016•