GW1--07774_Well Construction - GW1_20231201

1.Well Contractor Information: ®3 7-e I _
Chtii-
CAL%Q-1/// ,•T4.+WATERZONES`..;,. Mi.t;tNek; `iti'e'•,`;$C.•r},t'::': 1`!.. .;*.::e:i t,::!. .t. ..
Well etocN.^me FROM , TO
ft. ft. DFSC(RITTI�INIry1 .` I3 s //ryry,2 y�
/l 1! A4 e � ,4
fc. it. r p®/n.1A17 O`t2?
NC Welt Contractor Certification Number $•15 O11TER:CASING(Sir l b"dwell))OR'LINER(iifa"'Iieoble).wo...,:::::;6;� %;
ille�� q/p 9 /75 _ ie FROM TO DIA METER ' THICKNESS �[MATERIAL
(//1 r /J {9v ft. ft. in.!
CompanyName ��/ � � -
°.i6 II`INER'CASING ORT[IBING:�edttid[tgiil c]dsetl:ludp)':'T3ari•:a<?:s'itii 7?,^;t,..
2.Well Construction Permit#: FROM TO • DIAMETER I TSICE MESS MATERIAL
List all applicable well construction permits(r e.UIC,County.State.Variance.etc.) 0 ft. /1) ft. f�cl 1/�e/ ' e ),r$ /
3.Well Use(check well use): ft. ft. �/ In.
:AT
WaterSnpplyWell: :'SCREEN:isn.,..$?r?;.`vfintiti: r7ii�)it:2:.!?:s'...?:' 2:tlii av;;ii�:' -::s i ii'i tip::,:::wi
FROM TO 7••, DIAMETER SLOT SIZE TIUCECNESS MATERIAL
IAgricultural OM •icipal/Public ' 0 ft. ft in.
Geothermal(Heating/Cooling Supply) f •esidential Water Supply(single) • ft. ft ;n
Industrial/CommercialOResidential Water Supply(shared)
y18::GROUTr:t::!'sjt.i.t: e�:.Mxs ?> :'tei:: ;:i 3'"i°:f7: :t=, i:. }:ill 3i: `.t!
. Irrigation FROM TO IERIAL LACFhiiiti¢Mr:TTHOD&AMOUNT
Non-Water Supply Well: 0 f� )°�17 R CAIIYA� �J• �[/ �
Monitoring [Recovery ft. ft. ����
IIagect'non Well:
L. Aquifer Recharge �GroundwaterRemediation R ft.Aquifer Storage Salinity Barrier =:�•'SAND/GRAVEf:PAGIC(ilaTERIbiel}:�a?a : .lrci::Mtis ti::a.c:stw:r': .c,�
q l ty FROM ?O MATERIAL EMPLACEMENT MEZHO�if
Aquifer Test �StormwaterDraiaage ft. ft. t
ExperamentalTechnology !j Subsidence Control !t ft.
Geothermal(Closed
. Geothermal(Beadn /CoolingRetu ) ther(xplainunder#21emak) •
320.1DRILLINGLOG aftaebaddi6ounlbbbtsifiiiensa =4-"e. ;? irr:;•
FROM TO DESCRIP IOM(eoror.bnxa srmelstlye. ea.
J 1
4.Date Weli(s)Completed: I f/`1- , 3 Well ID# . . lA5 ft• h3 a ft: ref -i i r o
Sa.d e cation: ��O is 31'• it. / ve q S�Q li l..e/`/7�I%�
kiciltlylOwnerName - Facility ID#(if applicable) ft. ft. L._o a, ; l f• 1
3
3 %C ig4-/ J/'/lie Di- 44 1/PX ft.
f DE- i ZU13_,.�..
Physiptl�&lass,Cyy,andZip _ 4
P---�' , &e It 4211REMARIGSNnip..:::;-W.Fs`: ii'ltfir..,_, ' '7'~ '.:p^:.�v:'::`.•:'•vz;i..,.
• A is .:I 73i
. i`i 1
County ,PaccdlaentificatienNo.(PIM _ ra= , r..,.V
56.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
Myra E„Yd,one Padlong}is sufficient) l 22. erWication:
6 t (mae)thewell(a).1.04rmanent or °Temporary oof eitI0ee►►d Welt Con•• 4Date
� By signing thin form,d honeby are that the well(a)was(were)constructed in accordance
%Is 46is at repair to an existing well: °Yes or. 1 o rvithl9ANCAC 02C.0100 or ISA11C4C 02C.0200 Eelt ConstwctIan Standards and that a
fights is a repair.fill out known welt construction Information and erptath the nature ofthe copyofthls record has been providedio the ivell owner.
repair under 921 remarks section or on the back ofthisform. •
23.Site diagram or additionalwel details:
8.1t<orr tt;eoprohe/10PT or Closed-Loop Geothermal Wells having the same You may use the back of this page to'provide additional well site details or well
construction,only 1 GW--1 is needed. Indicate TOTALNUMBER of wells construction details.You may also attach additional pages if necessary.
- drilled: i
gmtvriTTAL INSTRUCCIOlYS
9.Total well depth below land surface: 3®® (it) 24a.For All Welts: Submit this form within 30 days of completion of well
6'ormultfple veils!Ere olldepthstfdyfirent(example-3@,200•and2Q100) construction to the following:
10.Static water level below top of ca4sing: 14 7 (ft.) Division of Water Resources,Information Processing Unit,
Ifwaterlevel Bs above easing ore 1617 Mail Service Center,Raleigh,NC276991617
Il1o13nrelnole diameter: (in) 24b.For Infection Wells: In addition to sending the form to the address in 24a
® l"' above,also submit one copy of this;form within 30 days of completion'of well
12.Well construction method: e�:77 / construction to the following:
(se.auger rotary,cable,d'irectpush,eta) .
Division of Water Resources,Underground Injection Control Program,
MR WATER.SUPPLY WELTS ONLY: 4..Lt 1636 Mail Service Center,Raleigh,NC 27699/1636
13a,Yield(gpm) 197 Method of test // ``` f• 24c.For Water Supply&Infection Wells: In addition to sending the form to
J the addresges)above, also submit.one'copy of this ibrnt within 30 days of
Il3Po.IIDisitriee(hon hype: �/ Amount: completion of'well construction to'the county health.department of the county
• where constructed.
•
Form 0W I North Carolina Department opEuviroeneats'Quality-Division of Water Resources Revised2-222016
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