GW1--05360_Well Construction - GW1_20230818

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2.Well Construction Fezmit0: °)l7 ^�I 0 u FROM TO mamma ,. re¢csno= mATMAL 1,
Liston COB ca if'otilotnaft'tt?ea Fl7eJM(1.c.ERA Cac=tl;stela Verieacx etc) m ft. `-ln;
3.Well Use(checkwellwe): ft. ft. tn.
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WoterSupply Welt: 17.SCREEN (j
Ili Asticoltrmral �IVlunicipallA'nblic FROM TO DMAMI TER SLOTSI=E -MUCHNESS MATERIAL ,
ft. ft, in. If
ICxttherwnl(Heaing/CooIingSupply) HResidential Water Supply(siogle) it It In.
1111.-iadustrauCommercial Residential water Supply( )
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is.GROUT
feria' neon FROM TO •- MATERIAL IfytPrAcr-QnorTMR[FfOn&AMouNr j
Non-Water Supply"Well: 0 ft 2..2 m s
3K Monitoring Revery Injection Well: ft.
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Xi •quifa Rech ft. ft.
e ft.
10 • •=Storage and Recovery DStiinrty Bier FRO,SANDlGRA�yffi.PACK(If EMPLACEMENT METHOD
II-quiferTest DStonnwaterDrainage ft ft.
*Emperimemrd Technology OSubsidence Conhol R It
VI r Geothermal(Closed Loop) EtITrecer 20.DRILLING LOG(attach ad t?ona?slimes if ems)
f' ill+Geothermal(Heating/CaolingRenrm) OOffier(eaplaiu under#21Remarks) FROM To Dr3cmr•rtowe�r �roarrm+x�� t
II fL ft
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4.Date Well(u)Completed: 7/Z /2 Well D o it 26( f R0 A-
5a.Well Location: ft.
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Fmlitp/OwaerN(tamr t FzclliryID#Crfapplicable)
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Physical Addtcss,City,and zip tL ft. A U G 1 e? loll
Ya IA ttr 10 2t.REMARKS tr L tt L J
County . Pateel identification No.(PIN) _ IR orrt'.4i^,7 :a.•.,.sr-_:
5b.Latitude end longitude in degree:/minuteslseconds or decimal degrees: DiA1 � Lilt,
Orwell field,arc la namg is sufficient) 22.Certification:
'36, (`1219 N &ra.`26623 w
6.Is(are)the woll(s)�✓pPermanent or Temporary Si®aamro ofCera eu Coatrnwr D
j� BY sign►ns liar fora&I hereby oerty that the null(s)ant(trem)constructed in aceoniance
7-Is this a repair to an existing well: al Yes or No lath 1SA NCAC 02C.0I00 or!SA NCAC 02C.0200 Well Conrtructton Standards and that a
Phil IIarepale Jill outduonervellouatfuctlonfnformaii erphttndtenativeofthe copy ofthis record harbsenpmvldedto the Ur1Iowner.
moatrander lin remonisseei(on or on the back ofthisfonn. ,Site diagrnmoradditional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use'tho backof this page to provide additional well site details or well
ctmstruction,only 1 GW 1 is needed Indicate TOTAL NUMBERof wells constrution details.You may also etch additional pages if necessary.
SUBMT1TA1.INSTRUCTIONS
9.Total well depth below land surface: 2.6 5 (R-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple walk lint aedepths fifth fefent(example-3®200'and 2 41100) construction to the following:
10.Static water level below top of casing: (I 0 (ft.) Division of Water Resources,Information Processing
Unit,
!floater level is ahem casing,sae+- 1617 Mall Service Center,Raleigh,NC 27699 1617
U.Borehole diameter: (7 OD.) 24b.For Iniection Wells: In addition to sending the farm to the address in 24a
12.Well construction method: CO Si-o
above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) constNetion to the following
Division of Water Resources,Underground Injection Control Program,
FOR WATER.SUPPLY WELLS ONLY: 4 1 1636 Mail Service Center,Raleigh,NC 27699-1636
13e.Yield(gpm) t 0 0 Method of test: k4(Al/ 24c.For Water Snooty&Infection Wells: In addition to sending the form to
I the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: l- Amount:_0n L completion of well constmctitm to the county health department of the county
- where constructed.
Form GW-t Nolth Carolina Department of Pnvimmnanml Quality-Division of Water R mources I Revised 2-22-2016
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