GW1--02144_Well Construction - GW1_20240409

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CONSTRUCTION _ . .
•. . ..WEL, RECOltio., GVV-4 .; . . . .
• 'for Internal,Use•Only:. 1 - - - • . . -7-7 ' - ' •
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•I.Well Contractor Information • . • •
..:Gary Thompson .
•;-. Well CoottactOrNemo" " • ..• FROM TO DFSCRWTION '- • •
• •••• • - 4418-A . ' .: • - - • . . . . -.: .a6S.fr*. 9.66 ft*. : '.. .r.4'cito. i..• :..1. WIA.:- • . .... • • . * . .
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tqc.Well Contreictor Ciaitication Nambei: • * ' • • ' • . . '. ‘130.#'. •43.1..a. Fc:ciltAiiit:.. .:Hci.Erttk • ..: .„ • : . ' -. . -
. • : ';15:OUTER CASING.(for multleasederins OR LINER Of. Sable), ' ' •__.: • • .•.
.. . 'Aqua Dr111;Inc.:- • . • • . FROM.. . l•TO . '1 DIAMETER . .. THICKNESS. • -MATERIAL• •.. - . - .
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• . . , ••ComiHo Nathe: -' • • ' •• -. • • • • .. • • -' :0• • •P!'I:14.0'•f!': . IL ...SI*: .' :. •-.PVC:"I6.,INNER CASING OR TURING(geothermal elated-loop)• • - -'... - .- • • • '-
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Well Construction ierinit fit,• 395•S .. ,. . . . ..1 FROM. ' .T0'. .• - DIARIETER. • TEDatNEss- MATERIAL -
'•List all apitlinibleitell etnstniction permits(het Ulf.Coinzty,&eta Varlane4ete.) - . ' ., - .lt. : • '. 'ft; - l• : ' hi. " • -.-: • ..
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3,Well Use(check well itse):. •, 2 - . : ':" . , .., • .. . '11,.. • •••ft' : • . :• :ID! ••. •• • ..-.: •• • .. • . -,' • . • • • •
• .. Water SUM*Well:: •• • • ' . .. , •: • . •• I- - ' •• • • .F.RvLOST:R. !EN: •• .-:-- ;' - I -ii; • -. • • ' - • ' ' • ' • •' ' •• . . '•
- • - Agricultural - . . . . Elmuniciiii ... .ric.. 1: : .. . : TO ft... DIAMETE"Int.1• LOT SIZE .. •THICKNESS • -MATERIAL
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cleatheLMI4(Healtlige,0011Og Supply)% 10Residential Water Supply(single) •• : • : • •I • ' - I • - - . ''.• . •• ' • . . • ..
•. ineluetiiaUC•ommercial - E3Resideadal*ater Saptly(shared)• "IRGEOUT
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Irrigation. ,, -- ' , :• " ' • . • ..: , . .1 ; " . : ,; • FROM . •TO -.-_ • MATERIAL ..: •EMPLACEMENT METHOD A'AMOUNT • .
NOR-WOOL'Sup*Wplli. -• ' ' • • - -' • • L • .--, . • 0: .fL. ., 1.0.:.:R*. •°?4 '4rig_e ••• ••• :•-,filiji• i'.144a.iivat .. •-• • -• •
' Monitoring-. " • , •• Recovery: ...-'. .- J", • ;. . .. " •ft..• . - ..ft.• .' -'. 1 - • • • '- • • '
Injection Welk ' " - " "
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Aquifer liechiugd - 7 :btinilindWilte 11
rReilleditItipil• .. . • •: ' - . .. - • • - - • . - 1 - • .:
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. -‘ ." •_ Aquifer§toiage and Recovery • .'-DSelinity Barrier f• •'. • snow • TO •• •.-•SAND/GRAVEL PACKS M(applIcable ATERIAL . . • :EMPLACEMENT
Aquifer Test • - - EiStonnwatet Eliiinaie• ," .: • : ...it7 : •ft.: : " ,, I. ' ., .. • _•• . * • . . .• , .: . •
pipe:hi:eats(Tech:et:logy. • • .E3Subaidence&Mind- • . -2_,•n".- • •!t " • " • -1•• -- • • • ' .- • • .. • . ' - :
- ' • taiotherinal(Closed Loop)- - -s - DT:neer .. • "- .- _. i ' -20.-Drin:LING LOG(attach ithUtlomil aheeM if aereasary)"-• '•--j. --:. '•••1• .-;_•-.- -
.. : Get:the:Mai(II CatineCtioling'Retutn)-•.110thcr(6tplain'untiat 012i RemOilm)" .- R. !!3'. • •T° " = •• Dzscawrum("*"r!
. .. 2.- . • •:.. - • • "-. -.0',•ft': :"IS .:ft*:- ...tit I Cie.. 1:lb;r4 . . . - - --,--.. • - - -
4,Date Wilke)ComPieteil:.3#ae-..I.4*•..ieu1D#, • _ ., • .• • :is. ..1.L.. •tit', IL, .•.$4.. ficili . - .0ii... , .:' i . . .. .:': .: • . : :.:. . ,
ga.iirellLocptIon:• - ' •• • • . • *- - ''. 1 1$: . .ia.o. . .• • 6 rani ie". . .. : . ' .. ..- - • ..
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. •AtiihOrti •Crt..1*n S . ' • ' ' : . . : •!.. . . : .13.0: : . 1ft.- . . 6 retntici,, ,..._, .....„ ...:,.. :. •-.... • •. . •&cm,triveetNeme. . - •.. -: • ,. ... .Facility Toff(if applicable). *• - - ft*. * *-11'. .1 ,4:,,L-",:r1/4...,L:i. vis,'Ii7. ': . • . '• ..
4804:•dici el.NC: 1114. bit: St.,-NAcdn'at.covt.,:. iliisa: -. ' :. _ - .:ft.- "._ . ".• A.. I - - - ci,• .1:,...2.•0.2.,..1 .... , ,. .: :. .. ".'
Physical•Addrees;City,and Zip - • - • • - f.
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Cianti-
". Panel Identlileatton No.1(11IN)• • - - - - - - • - • - • - . Di."‘101.?-11,X;
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Sto.1;ntitudnanti longitude In.degrais/mInuterismonds or decimaidagreeee • * .•*. • ' •" . - - • ' " " ",• - .' ' •--• --• • , ,
• .,,,,,...,...Ofwelyfield;one let/long is sufficient) ' - • • • •
-7!2.C.:ertlfleatIon: ": . •.. -. • : • ', • . - • . - r - •
• • At:3.31901.-• .. • •• •If. -•t0.2181011 '• : --. . i .. • W- - . : --•• • - -,.- - • - -. - - .- - - . . 4, .- , • - • • -Li- . ,
_ 6.:,..):„Ivell(s)Cglieriiiutent . or Temporary • • •5'i'. " ell -- - i. ; -
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Ick4=A-77..*. • - • - .2.'-
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•Date . - • ••
.By itgithlg ditiftrin,theseby cm*that the-livil(s)ivas(Iw).cOnstisicted in aecerdanee
-k-7.1e this a repair to an existing welli. *.OYes..or No : ' •': :with 154 NCAC 02C.olop or!SA NCAC 02C.0200 Well Constrtiellon 5*u:dot&and'that a
ehls 1 s a ri7talr fig onilatawn 1411 Conitnietion*Million and elphihrehenatthe of the. ..c0P2'0l.1ith record ha:been Wiwided to Ali'senowner• - •
" .wale under#21 renter/is sifillentron Ike hadcrif Ate fem.. .• . .. .!. - - ' ..- -. • ' .
- - , . . . . . • : - • . . ' • . • -. .. • • . : :L. -. : -23.814 migrant isr:addltkinifwell details: * ."-" -. • . • .
.8.rerceeprebeirditot coitis-teezi Ceetitermei wens ii.m;ifig tie seee. . "Irl'il may Indicate TOTAL NUMBER wills usi.thelack if ihig.Pko b4:*6/406 additiimahvau site details or well
constrtictiOn;only 1 G6V,Iit needed: '
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.cipaftucaon laatatli.-:You may also attach additional pages if neceisaty,
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. . .. . - . •,":": .1 .:. - ••simmiTrapi*STRuciriciws.,
• . 4:l'ehd well;kith belivt!siid surfate:• .. .* ; Milz..- ... ... .. (ft.): :24e.)Foi MI Wells :Submit this form Within-30 days of completion of well. .
•For*entitle ivelli lir t al l*1 la trAlffertnit(exampler3@200'.cintl2p100') .: .! : . 'contftuction to the•following,
.40.Stade inter level below top of teeing:. " •,- - 601: , . •,,, •, -(e.): .•. •Dlilidon of Water Rem urc4 Information irocessitqf Unit,- .• .
•.ljuutei level Is Om etisini use-"+ ' : • .' - •
' 1017 Midi SIT*.Center,Raleigh,NC 27699-1647 •
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11.Borettote•dhuneter:••,_ ':- .6 _ • (In.) • . .
24b.FOVInieellon*ells:.In addition to Sending the Toth:to the address in 24a - • •
_ •• eke : . • • above,also submit one copy of this form within 30'days of completion of well
•12:Well cetistructiOn.Mithed: •RCA Ca .. MIT.- . . ;. . . constai,iicin to the fogoivint
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(i.e.quad:FeeTry.eabytOreeet pusli,eta.).. . ' : . : • , : .. i. , . -
.- . ..titeliton.oiWitier Resources,Underground Injection'Central Program,-. • .• .FOR-WATER SUPPLY WELLS ONLY:. - . • * - - - : . . • •1636 Nail Berrie;Center;Raleigh,NC,27.6994036 .
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__:.I ! • " • _ ,. - .' • : •13a."Yieid.(gpm)• • •SO: - . ; .-mettrod Of test. •diviter41"iitit. 24e.•For Water Suuatr-&ItafecuoitI Wells:'In addition.to sending.the form to •,- "_.._:, • . .•. .11. 4..11 ,,n•.04 , • , • •„ ..! • s • the address(es) above,also submit one:copy of.this form.Within 30.days of" : • . ..
13b.DisInfection'typer.HI IV .1‘10%IP. Atioimt: ; __-- iptit;' .: .completion of well construction to tlin:county health departmeat.Of the county.,
Where constructed. ••
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• Form( ‘il - . .. " NM*Welk:a itepaitionitOillaiiiontiimeI(baditY.MR:on eiWeter IMMO:oz. - • Revised 2.22.2016 -
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