GW1--07406_Well Construction - GW1_20231117

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2.Well Construction Permit#: II l/ a •
( FROM TO DIAMETER' ' TRraalr$S MATERIAL
tiara oppiimbrewatica,ruuedanperm/u tte.UrC,County.State.Variance.cm)- ft. It 'to.
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3.Well Use(cheek well use): ft. fr. inn.
WaterSaPIdYlVeu: �.1tiSCRE1 �Ts _-e•<_ a-L . -; : =w=l�v=-cliv •
-e utp 1u FROM TO DIAMETER SLOTSIZE TLiCkkNFSS MATEATAL
1 Muni' tic 0 it• rt. JD.
©Geothermal(Heating/Cooling Supply) Idential Water Supply(single) tr. R in. •
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aIndustrieUCommereiol _ DRos deutial Water Supply(shared) "' J.' R,�_ �
:Irrigation FROM TO MATERIAL ROYIACEMENT METHOD ag.ta:OUPTP
Non-Water Supply well fr. ` m r
)Monitoring ❑Recav �� 1 — kv hJ `�lrvi. a,rv { int.,
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Injection Well: - .
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OAquiferRecharge rjGuourrdwnterRemediation t<. R' -
�A4Wftr$rOrageandRecovery RSali Barrier VTR AND/GRAVEliPACK;rcarngaibio)<-.-,r;.;., -:�,L `-_ TMr121_,: :=: -
L! FROM TO MATERIAL' EMPtACEMENPMLTROD
_Aquifer Test -OStonnweter Drainage tr. tr. •
Experimental Technology EjSubsidence Control D. ft. .
' --- .Geothermal(Closed Loop),.:. rITracer - - =sfaRILIDNGEGG(.ififi aidl'cienaivtieitr"tta:aiaiiii= _ _:• ••
YROM TO oes nvnoNfakir.hndnesysdtrtorlt�jeminriwe-.Geothermal(AeatingfCOpinigltellarl) ElOther(explainunder421Remelts) uJ/ �j O 14 O R n /C(G
4.Date Well(s)Completed:F )" !'o ? Well mt 3 b h 1.�/ fr o fe"'^1
Sa.WellLoeatioru /lc/ it �S Gnu. 7"--7-- -C..-
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L a/a/ L o(Ail 61ti/e .! gC, S Fs - t ft.
Pacally/Oaae=Name Rain/la ll(lfippticabb) to It. .
• SCt� 1 f4/1 G76-4fle0/4_ Ca? a.S� ft. .;,.:
Physical Addceae,City,sad Zip ffi ,�' • u,A,i
Cotuuy %maiden:1St:lino No.(PIN)
• Sb.Laflfudeandlou longitude 1: !� i.,r>>•
s Ei l greeshniautesiseconndds or decimal degrees: A _ :.i
• �✓ G J�rf�n�lJtO sufficient)N �! p L (7 � �� 2ZCertification: �1.4 g g" a ��J
/ W "" ', tQ. Pktilei i 1 q.s a;
6.Ware)the weigsj Permanent or QTemporary Signature eniHedWellConaacror Pile
�,,� By It'll*this form I hereby eergtj•that the well(s)war(here)eoranneied in accordance
• a 7.Is Ibis a repair to an existing went DYes or r1Ai`o with 1SANCAC 02C.0100 or 1SA NCAC 02C.0200 Well Canonic:Ion 8tandotdr and that a
fads is a repair,fill out known well contirection Warrenton mid eaplam the nature qf the OW old*feemd has been protvdedlbthe!Nliownu.
repairvnderO71 remarlr scalar ar0n the hock tOttsform. .
23.Site diagram or additional well details:
• 8.For Geoprobe/DPT or Cloted•Loop Geothermal Wells haying the same You may use the beck of this page to'provide additional Hull site details or well
construction,only 1 OW-1 is needed.Indicate TOTAi.NUMD13R of wells construction details.You may also attach additional pages if necessary.
drilled:
SUBM
L/G � ITTAL iNSTR ICTION�S
9.Total well depth below land surface: (n.) 24a. Par All Welk: Suinttit this form within 30 days of completion of u'
For metaple wear Avail dept&fltifferear(esample.30200•and 4100) eanstuetionto the following _
10.Static water level below top of casing: 7 .S (rt) Division of Water Resources,Information Processing Owe,leveltrabovecariigWe+" g Unit,
•
77� 1617 Mail Service Center,Raleigh,NC 27699-1617 •
11.Borehole diameter. U7 d�.1 (In,)
t / ?rib.FOY Inlectlon Well: In addition to sending the farm to the address in 24a
12.Well construction method: Pv rice'( - above,also submit one copy of(Ids lbtm within 30 days of completion of well
(i.e.auger,roue.cable.Cued pull'.co.) ��/J - construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Centel,Raleigh,NC 27699-1636
t i ,
13a.Yield(2prn) 5 Method of test: f r fJC-deter 2 tc.For Water Snooty&Inlectlon Walla: In addition to sending the form to
M Li the address(cs)above,also submit one copy of this form within 30 days of
• 13h.Disinfection type; t ' S a Amount: ?r `j f completion of well construction to the county health department of the county
•
�1' where constructed.
FamGW-1 Rot*c a.mpanmaotafEmdmameomlQuality-Divirioaof Waterttwoanes Revised2-222016'