GW1-2021-01706_Well Construction - GW1_20210209

WELL CONSTRUMON RED (GW:1) For hft=l Use Only: .
L Well Contractor Information: -
a .A.WATERDUM...
well dame
FROM �TO DEStON
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NC Well Cad&dosCatiScatinNuinber MOUtfsR04MG 'met ed�' ORTam if
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3 3$7 s1G.1NflH8Rt.ASIDIGOItTIISII�16 ..:
2.Well Construction Permit#: FROM 20 DIAAgrFB TEMCHIMS ` MAZQtrer:
rrs:as coftm ble welt amaaacttanPOMM ru WC ComuY•SAze,;r=w e,rJcJ & tz 5 hL
3.wen Use(check well use): & t
Water Supply well: sue:_ iceMssetwr.
FROM TO DIAMETER
❑Agic ukmd ❑M1micipal/Public R is
13Ge0flM=al(HeanaWCoohng Supply) ekse en- Water Supply(smgie) g is
Oindustrialcommacial ❑Residential Water Supply(shared) la'.GRODT
13krigation , ❑Wells>100,000 GPD FROM TO MAC. F1C?4dC&►IWAKE=0D dADtormrr
Non-Water supply wen: R R AA; el
❑Monitoring ❑Recovery �t rj't2r+rt ! Cl n+ t
Injection well: ft. j
❑Aquffw Recharge C3Gmundwater Rmediation _
i79.S.4PID/QtAVELPACK' ��=-"-_ ••-,��.-'"T �•.�:�_+s�n - -
❑Agmfrd•Storage ad Recovery ❑Salinity Barrier • FROM TO MA1ERrAL n�iwcnaarrr�en ..=
❑Aquifier Test ❑Stoamwater Drainage >;
❑FDVerimental Technology ❑Subsidencx Contrtil $ R
❑dal(Closed Loop) ❑Tracer ^2orDRnJMG WG at s dition>taLerls'if_ _.ti _;`20 :,
QGeothennal(S�CoolingReinfn) ❑Other(explain under#21Remarks) FROM To Dffi�riON aWi eta
4.Date Welts)Completed: ZI Wen ID# $
5a.Well Location:
$ a.rlL-
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Cal+ S.PAPA oNs.Cms��Co
Faa7uy/Owner Name j t Facft 1D4(if able)
N L 6 MCctri �-4 n 5 1r 0' ? d ., tt tt
Address,Q1•Y aad4 8 ft.
ICL✓ � ZLR>SMAB)iv5 -':-.-
Cy Parcel IdeatfficationNo.M
5b.Latitude and longitude to degees/minut�es/seconds or decimal degrees:
(if-ell field,one g is ) 22.Certification:
36 U.' S617N X6 ' 41 ` / � wLat - e2-5 l
6 Is(are)the well(s): t9Yerm ant or ❑Ttmporary �J� I_ Sigma o eIICoatr r » I
-'refit was(were cs�sam�Pn r�owx#zxe do
7.Is this a repair t0 an eriatiag wdl:' 'Oyes 'ot 15ANCAC o2c woo or 15ANCAC o2C.0200',Wreff Cmmuc m&wxkr r mad d=a cap.
ff*s is a npafn fiR a d brown web cmunranon mforxarron and c#abz the nmwe the of this record has been pn vidad ai the weII owner.
repute fader21 reararks seetlori o�an the barE of tTasfornL`I..,� V C� 20 � 23.Site diagram or additional well details:
S.For G;o brJDPT or Qe -too Geothermal wens havumgA tlle.same You may use the ba*of this page to proovide additional sell cousbubdon ialb
P?b P k a s;�1f add'See Ovee in Remarks Boxj You may;also attach additional pages*neoessal
won,only 1 GW 1 is ri�eeded Indicate oi[OFAI�NIJM$Eltufw4ns' ``
dulled t s 1 C i1 24.SUBMITTAL INSTRUCTIONS
9.Iotal well depth blow hraN surface 0 (fL) Submit this GW 1 widillin 30 days of well completion per the fenowbw
For sudttp(e wets list aff depth if dmt(—mple-3(a)200'and 2@100')
24a. For All Wells: Original form to Division, of Water Resour i (DWR
10.Static water level below tp of easing (�) � �p Uait,1617 MSC,Raleigh,NC 27699-1617
If sraoer tend is atwve oositrp rse +' � ' i
�� 24b.For Injection Wells:Copy to DWR,Undagmuud Injection (IU(
1L Borehole disnxter. n {m) P1�1636 MSC,Raleigh,NC 27699,036
12.Welt conshacdon meti<ot�: f`0 E d L. A• t' I
ppoa��,, 24c.For Water Snaal'p and Open-Loop Gcoffiermal Return Weft to tb
(Le.��9.oaw direct ..I �), 7 � county envira menial health department of the cocmiy Wh=mstailed ..
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells pkodum over 100,000 GPD.Copy tD.DWR,CCPCU
- PermitProgam,1611 C,Ralei�,NC�77699-I611
13,Yield(gpm) 1 Method of test: /r
13b.Disinfection type:_ !1 Amount:
Fora GW-1 Nor&Cmlia Depam¢ent ofEnviroemestal Qualify-Division of Water Resources R-v l&.&201
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