GW1-2021-00285_Well Construction - GW1_20210125

VMLL CON,STRUMON REDO, (GW-I) For dal Use only T-
,
L Well Contractor Information:
• , ' X 14.WATER7.01 s... , -A -e al Well Corgi Name FROM TO t I D�rrON _
30o ft. � ft
1
N�C Well Cc Cerff=rion Nmnher 15 OUTIR CASING i s weds OR Idl!BtR d
{V A m2+'� 2 yy, FROM T8 D16MSrF3 TclampaBI Vl MAIERL�L
9 148111c A&INNER CASING OR T[iBIIVG a1>tsmat -
2.WeliConstruction Permit tM 0 4-5 3 vV FROM TO J DIAbMnMR I TMEMON Iaye ret
zcsr all app&mble well o�csysetlan p—&s rEe WC Cornrty.Strom Vmi awe.etc) fL ('5 fL S 7 ; Yt�•
3.Well Use(check well use): R f. m
Water Supply Well
FROM TO J M M M I SUMSIM I TEMC51%M M.MPrer
QAgriculriaal OMunicipaU lic ft $ m
❑Caeothexnal(Heatuw�Supply) )(Residential Water Supply(single) R ft
❑Iadushi Comm" QResidential Water Supply(shared) 1&'.GRODT:. I:.; ::•:;._e.."'._': `;:"_.%':.5_-' E:`.'e`.:.
fl I'on , ❑Wells>100,000 GPD FROM TO MP,TEM" a"OUM
Noa-Water supply Welh D R Z 3 '� Nen t
QM.armoring QRecovery ft
Injection Well: JF'1&n r" �I
fL fL
QAqu*Recharge O(iroundwater Maediation _
- >19.SAPID/Q2Al�LP�.CB"�f-., ._ _s,_ E�i•:�_�.,.': . .,.
QAqui£a Storage and Recovery QSalkity Barrier - FROM To M&MMU&L ZMMACMMMMM
QAquiEerTest QStormwsterDrainage $ f
QF:xpe�meutal Technology ❑Subsidence Control 8 fL
QGeothermal(Closed Loop) QTracer '20'DBII.LIl�TG LOiG simdi additional he6ls'if `�' ' a>: ',:.... `.
0Ge0t6al Meatmg Cooling Retum) QOther(explain under#21 Remarks) FROM TO & DWCRiYIfL
SON Coto mel/reek etc}
i
4.Date Weli(s)Completed: !-!►-Z I Well ID# fL fL
Sa.Well Location:n
Faality/Qwnar Name Facility IW(if q*&cable) R a
CC. �0r, W DOG( !�D! ft. R
li
Physical Address,City,soil Z� R' R -
21-RE 4AIM
C—Ity L Parcel Ideation No(PIN)
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees:
(ti'wen S/ekl,one laviong is ) 22 Certification:
N OV l� W t/
6.Is(are)the well(s): ermanent or QTemporary 2-GO ' '� Date
Bysigting thuforn�1 hereby caafythm rise»eII(sJ was(were)c+oraarsud iitamvrdmtce wii
7.Is this a repair to an existing welly •Byes or 15A NCAC 02C:0100 or 15ANC4C 02C-0200 iYeII Cgrrw=%t ort Srmndm*me3 char a crnF
1•f this is a rrjbii fi71 ord brown well pvoa mjoracmiorr and the naa)rr�of the of rhrs recoirihm betnprvvidedto the well owner
rz parr miler 921-nark section or on the back of thisfarm
23.Site diagram or additional well details:
a.For Geoprobe/DPT or Closed-Loop Geothermal 1Vens having�e You may use the bards of this page to provide additional well construction info
constr u,tim only 1 GW 1 is needed Indicate TOTAL NUM
s j�(add'See Over'm Rem Box}You may also attach additional pages if necessary
dulled ,'NEB,
`'• 24.SUBMMAL INSTRUCITONS
9.Totallwell depth below land surface (fL) Submit this GW-1 within 30 days of well completion per the fallowing
For aadtr�le we11s list all depths ifd ffer�u Ce�P1e-3(a)?Q0',mt3'2V 001
24. For All Wells: OA iml farm to Division of Water Rrsotacxs (DWR;
10.Static water level below bop of casing: �� ( )
If warn k'wl is stove easag:vse••+
Intimation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/• (,
11.Borehole diameter. l/a tin.) 24b-For Injection Wells.Copy to DWR,Underground Injection Control(IUC
Program,1636 MSC,Raleigh,NC 27699-1636
12.Welt construction method: 2O A, 24c.For Water Sappls and Open-Loon Geothermal Return Wells:Copy to tb
(i.e. ,cable,ditxt push etc.) cou
nty environnen al health department of the cotmty where Ted
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wens�Prodncing over 100,000 GPD.• to.D
Permit Programs 1611 MSC,Raleigh,NC 27699-16I 1 .� 'CCI'cUl
13a Yield(gpm) Method of test: r}t
13b.Disinfection type: i+ Amount:
Form GW-1 North Carolina Departing ofEuvitonm=ai Quality-Division of Water Resources Revised 6-6-26}
A