GW1--06284_Well Construction - GW1_20241022

6 I, I N RD(1W-11 For Internal use Only.
1.Wet!C,atotzmctrar laferma1tiooa`:
✓ le n 6�A.. {�!/ /,5.S e-f'f a - r +� ,::' � 1 k >.;4:;
Well Contactor NameFROM TO DESCRIPTION
NC well CoauaatorCeatiBatioI'Number liter* tor visiva ,�
�} )) i�� f ' J PROM T O t I I TRIMMED- MATERIAL
(/ t :'._ t L'f" -// t/d i . �I I?(-
Coaraay WOOD _ Q a r p -rI'�t"'F#j]1 ;aa " r e i• ^rM•< ,erSS #+re.
2.Wen Cee eellem Permit ilk - V a TO DIAMETER „ 7 •MATERIAL
List aN applicable well conarucltotepermits(Le.WC,Cowry,State,Valance,eta) ft. ft. tar.
3.Weft Urn(dank well use): flu ft.
�YattwSagtplsWeu 2ifi . . -: . ,,:,:.a
met To alAt�" SLOT SIZE =COMM tNA7ZWFSI.
1 Agricultural OMunicipal/Public ft. ft. la. 1 •
R Geothermal(Heating/Cooling Supply) ;.'esidential Water Supply(single) )q, ft. is
i lnd atr JCamanectal III=Residential Water Supply(shared) h_ "4
IIhrlit ticm PROMTo MATIaL4t.I ' esaismeinsmanr sternOD£Manny
r
Weara C� a' ' +
Ns.-Wrier `
IS / R.ft. f ...
e8: °Recovery ,a it.
ill Aqui h� D `A._-.:... x .,. • y ,;.. 5
Rec Clroimdevatesr Rernediaaiaa ;t+ .fi f
Storage and Recovery DSa1umity Barrier FROM TO MAT At EMPLACEMENT fill:t eon '
Tat 0Stonnvater Drainage i
:III ,, Technology OSubside®ce Control , • ft. - ft. ,
(Closed Loop) OTracer 1 t.&Rt�ai IOC t e l i
-P's - •, 1, . . ., :Raum /'Other(explain under#21 Remarks) tart 7n n ackrir(rats,tr„a Ism'ai rro�c eye tub+de.,ate.)SvIrn-y_^F rr•e
%O,Th .N : 1-, .. -,..,..----7::,,,, •tF acflity.mlf(if apPlii lc). os �7-
:91-'7;tri)//y::Ra S r�err6- AI t?/o ._ .... :. n.: f 1 2 ..
,!!.la�!i. CoY.!PI?';8' G ,�—^�• _c 1T :. 'a f .,'" 1: (f tf
.+'C > r., •t. •:.. `tdR4-� ... ...... ., i• :}f'.13:,'�','y. "'A:trc-� ati u.
county Parcel Identification No.(PIIa ._ L',_ %.er,
5b:Lu1ilade Mid loagitdde Iiiidedreesiniblutosiseconde or decimal degrees: • '
(ifwell field,ow 1st/long Ia sufficient) 22.Cerdfssation:
A"- N 4/4 W /e e JJ��
6.Ie(are)the wall(a)t§Peuem et or r3Tensporary Slit*t ne of Certified Well Contractor ( Dos
By signing this fonts,I hereby certify that.the well(o)was(were)constructed in accordance
7.Ia this a repair to an existing well:_ ['Yea or a with ISA NCAC 02C.0100 or ISA NCAC'02C,0200;'ell Construction Standards and that a -
ritit 1s a repair;ji!1 out bows well construction information c3PJads the nature of the MYgthis record has been prod to the reel!nW.
repels mix.#21 IVXMFIO esrt6ow or al the back of this form.
23.Site dtgrafn er additiond well deeds:
S.For Ge®Prahs/DI''a'or Glared-Loop Geothermal Welk having the stone You may use the back of this page to provide additional well site details or well construction,only 1/�W-1 is needed. Indicate TOTAL`NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: /O,/9-- j
/ {{_ sl�ta-1"AL msT1fiUcrlcrlvs
c Total won a below land terrace: /its ( )
ear mkt*weans let aiil,'rpea gdprerou(example-3®200'and*IRO')
24.gar All Weill: Submit this form within 30 days of completion of well
ceaartttacdan to the following .
I
lit.rye water s of level below i dewing: • (It) 1)Fvltlon of Water Information Pr+ocenlng UuII
(f,wta tewt it abaer oast%use"+I 1617 Wan Smiles Cana;Rileigb,NC 276994617
. i26h gar.-inlet etas Weijte In a,,ditioa to seadit�g the form to the address in 24a`
/ f within f
13.`Vefl• a gale .. /�i . ' - !,constiuctio then 30 o don of v►ro
----
ver also-Submit one copy o th:s-foam• days° comple lla
•(i.e.anger,MOO:able;elitea:t psrah;",etc.) _ n to the following: f
_Divlion of WaterRe ourcs,Unl ca Ijeetlon 9Cenro1?rogam,..,.;FORWATERBUPFLY WELLS ONLY: . 1636lScnlce Center, NC 2769-1l36 13a.Yield(eta)'- - -'C_J ' Method of test: . if�l'S7 ig •-- - 2�c.For Water Snooty elk.Infection Weida: In addition to sending the form to
the addrea.(es) above, also submit one copy of this foam within 30 days of
13h, /? Amount: / completion of well construction to the county heath department of the county
where constructed.
Form®W-I North Carolina Department of Environmental Quality-Division of Water Rem= Revised 2-22-2016