GW1--05014_Well Construction - GW1_20230807

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K RECORD(GW-I.) .: For Internal Use Only: Losonnereonc---.--Print NMI 1 I
• • 1-Won, :
•-entramor Informatlare ..
CCrEtriantarlYnnic lg.WATER ZONES 1
FROM TO ,nrsourno• rt
r2G,Skt• ft- - '1
17E----- ----------en r.,., It. rt.
. Iv-—tette CmiruatinNumber •
Moia Drill,Inc. L9.OUTER CASING(for mald.eased wan AMMER(To) 'I
FROM TO DIAMETER TEICRNIER MATERIAL
0 ft. 9.0 ft 7 fn. 49(/C...,
1..., a
a•Well Constructio Permit th )8 6 i 16.INNER CASING OftT1)BING(e0lbssamtidttseNcon)
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' FROM TO DIAMETER TROCENESS MATERIAL
11
, -ee.coole null comer:teflon pone&(Le NIG Qua*State.Vorianc4 ate) ft. ft. In.
Use(cheeky/ell me): ft. It In.
Water Supply WINb .,. • 17.SCREEN
FROM 1 TO DIAMETER scars= THICKNESS -.MATERIAL
E3MIMiGipal/Public ft
1 '11... 1314°Ltumilai MeatineCooling SIVA?) r...4''esidential Water Supply(single) ft. ft.tistrani/Comommial I Residential Water Supply(shared)
1 ‘i*::-...,, a krigation Its.Guam . il
an-Wute Supply W FROM TO • MATERIAL MATIACIRMENT METHOD&AMOUNT
r ell: 0!
In ft' 7.5 ft• ,_/:1,.//pC
Ili oins-mg Oftecovery • ft. ft 1
jectionk Well: ,
• Red DGmandwater Rem:di:dim Et. IL
- it'.,' Storage and Recovery
OSalinity Barrier 19.SANDIGHAVELPACKfif scallrable)
FROM TO MATERIAL EMPLACEMENT METHOD
' ' 1111 •quifer Teat • OStorrawater Drainage ft. ft.
Experimental Tecluardogy • E3Subsidence°moat ft. ft
-,. NI Geothermal(Closed Loop) °Tr= 20.DII/LLIN G LOS(attach assukaal ateets If uteessary)
" it Geothermal(Hating/Cooling Rearm) ',Other(explain under#2I RIDIEdIE) FROM
. TO M3Salren°14(''18r.'112nizm'ulificgic Vim'gala 62.ttc4
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4.Date Weli(s)Completed: //,/,N/4-.,Well1000 .8 tp It. 705 fL (Z,c/f„
So.WeIlLocatitm: . - ft. • ft • '
IL ft. (..,..,.. .4:..:1-',.'s--... .,.
"0-e:.ine/4- joeie-e7 .„, . , i d 'r'"•1 _
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.. FneaDy/OcauxNarce Facility inke(ireoplicatic) , ft• ft ,, -......„,,,
2.!-icts/ /frc, Z6 Pitwtoc te__ it- a. 14 i i h a 7 9/191
• Physical Adders,CIty,sad Zip It.
55)-0 IQ-S EL MIMICS
"..„„;. County Parce11&rninottion No.(PIN) • D'..;•`:...,;:-.1,',-1(;) -
.1....3'..," . Sb.Latitude and longitude in degreasloshintesfseeonds or decisn' al degrees:
(rwc11 ficid,one lat/Inag is sufficiag) 22.Certification:
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• ertified .
6.Is(are)the wergapiermonent or Ellrearponiry Signs=of C Well Ctmbrztor
By signing Ms fans.I hereby co*,that the sveUrc)NW 6101210 constructed in accordance '
•, 7.Is this a repair to en existing well: C3Yes ortt with ISA NCAC MC Med or ISA NCAC WC.02.10 Well Consorted=Standards and due a
Irthla a
I fill out known wet/construction Wormer crud the regard afore copy of this record kW been provided 10 gre mil coulter.
Is ,
, repair under MI remarks section°ran Ole bade qf thts fano. 23.site diagram or additional well details:
1 '
g.For Geoprobeappr or cioEsmigep Geothermal,weths having the etime ceastzuctionYon may usedmilheisback.yooufninythis abopageuttachto proaddivide_adifitional we. 11 site details or well
tonal FigICO duecessary.
constractica„only 1 GW-1 is needed.bateau TOTAL NUMBER of wells
I
drilled: MannaidejTM1c2i11
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9.Total well:IVOR helm land surfeit.: 5 125 (ft.) 74a.For All Waif: Submit this form within 30 days of completion of well
Formuldpfe weir lista fhlorhr if&roma((ample-3®ZOB'anr12@l0D') contraction to the following:
* 10.Static water level below top ofeasinx gel . (ft) Division of Water Resources,Information Processing Unit,
If au"÷" 1617 Mail Service Center,Raleigh,NC 276994617 tvater level is aim a=its
11.Borehole diameter: C (10 24b.For Infection Wells: In addition to seen the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Cater) ./_,....;..-------- construction to the following
11.e.CUM;rotary,cable,dinxt push etc.) ,
Division of Water Resources,Underground Injection Control Program,
FOR WATER S LY WELLS ONLY 1636141311 Strides Center.Italei'gh,NC 27699-1636
IMP :
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*.tf r lir 24e.For Water Souralv&Median Welds: In addition to sendiog the form to
138.11eld(gPm) • I • Meth°6-..f-- the arkitess(es) above, also submit ORO copy of this form urithin 30 days of
health department of the con
1311/.Disinfection type: it _t Amount-...:-Iga-•--- reteletilmeonstrourcLiell mnstnictign to
the county
' 1Y
Form GW-I
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f Environmental Quality-Divhion ofWater Resources '
North Calolinsliellutmed° ' Revised 242.2016
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