GW1--05813_Well Construction - GW1_20240926

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IL.SCREEN AfER?AL
I M Iner Sttpph t,rR. FROM to DIAMELER %Lot SIZE L tit/76.x57_- b- _
'._1cn:uanrnl Ll\luno.ipal Pul'lir. O R. //4511 Ir' In •ZIr ( .OZ r' L PvL__I
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Covilapi.1 Ktesidimtial Water Supply(siaplc) D, rt. In I
(.-Ttduanrd'Cotnmai;al ❑R.si. ntial Water Supply(,ItntPd) 1
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,'Irt mitli,n DWelis'-•FIOIun)(iPi) MINI r0 MATERIAL PNPI.SCEtfrl►T bs:11UOA .w+.R lst T i
inn-Water StpplrWelk U OR re(1oni;C r
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iinjection Mehl:
1 7..7.1quifer R:charge OGroundwater Rcmodiatitn
19.SAND/GRAVEL PACK(If eppllrable)
1�A tile`s Storage and Recover!. ❑Salinity Ramer FROM TO -M,UI:ItIM, EMPLAC EVENT NG.n100 ,
CAqui fcr.Tizt OStomtttater Drainage 0 0' l u s 0' #3
L'1Espenmcntal Technology °Subsidence Control rt. R
DCnotb-nal tC ose.i Loep) OTmccr 20.DRILLING LOG(moth addntonat sheets If necessary) --1
FROM ( TO OF_SCRIPTION robe,bArdne.a rlY.ork type.rFsin du,..
,;Cent.',-m:al ilicannn_Coding Return) ❑Other(explain under all Remarks)
4.Date\\ell(a)Completed:S d1 Well If a. it St "` .. .r.4 LL j�^.' f
Sae Well Location: (/,� 1 r "!! i �,.:
6340 {tip�crle Jo R.
R.
(�{� A
/ R h. JLr 2 o 2024
Facility Ma(If
f aappitcaable) /�
1746, fcskOII tnj kiere Rc( !14 hviiC R irf.,.tAo. ; ' a :
Physical Adaresc,City,and Zip (V'• .1...;.,:.
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• 21.REMARKS
Parcel tdeotifiaat on No(PIN) Used steel hardened drive shoe
b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
wc1'(kid,one lavtong is sufficant) 22.Certification:
35.54°i02 N -71 .949Sp w rY S"-dt-ali
6.Is(me)the well(s): CFcrnunent or ❑Temporary Signal a err tie ell Comm r Cax
0y signing Ibis forma 1 hereby ce )Si that the weft(s)was(were)emstrac:.d in aeeerdcncr.'.'
7.is this a repair to an existing well: ❑Yes or el No 15,1 NOW 0 C.0100 or(5d.VCAC 02C.0200 Well Construction Sand vdr and,'.r•at a a.:.73.
^is ra a repair,fill oat Arown well construction iltformanon and erplm n the•nature of the of the retard has bean provided to the well owner.
repair under 021 remarks section or an the back of this form
23.Site diagram or additional well details:
8.For Geo robc/DPT or Closed-Lou Geothermal Wells having the same You may use the back of this page to provide additional wall corm uctien iniJ
P p g (add'See;Over'in Remarks Box).You may also attach additional pages ifneccuorr,.
construction,only i GV.'-I is nxdai. Indicate TOTAL NUMBER of wells
drilled: S! 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /`/" (ft.) Submit this OW-I within 30 days of well completion per the fellowim:
For multiple wells lest all depths ifddf•rcnt(example.3(r2CO'and 2(u)100)
24a. For All Wells: Original form to DtSisicn of Water ii. e&(D';,"
10.Static water level below top of casing: 6 (f-) Information Processing Unit,1617 MSC,Raleigh.NC 1?699.1617
if water level s above caning,ice" "
24b.For Infection Wells:Copy to DWR,l gr:ndereaai*diva Corn!O
11.Borehole diameter: 611 (in) Program,1636 MSC,Raleigh.NC 27699-1636
Rotary
12.Well construction method: 24e.For Water Supply:out Opal-Loop(,cotiwrnul Rettant wall=Copy sat%
_. _„•r,r^:..rye cable,direct push,etc) county talvlronmcntal health Ogiort ent,;f ds.:::ur.h vr.- a.,t;r.r
IOit\V,1TElt SUPPLY WELLS ONLY: 24d.For Water Wells priaduciitimsolOar GIFD:C.vyto EVAR QL•IP('L'A
SD Blow Permit i'mr_galn.11,11 MSC.I aler NCI
E
I3a.Yield(gptn) Method of test:
lib.llistntictiun type:HTH Atmunt:
PLuth Carol to Depattmrnt,I[nv,wnmrotal t;luakty-Dice.n tit'V'autr 0.,:,u,.ea ..:,tali 4f-20-a