GW1-2021-00556_Well Construction - GW1_20210226

WELL CONSTRUCTION REM (GW-1) For Intemal Use Daly: '_
L Well Contractor Inbrtnation:
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3.Well Use(check well use): &
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owes tidd.offi 1 is sulk) 22.Certification:
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6.Is(are)the weIl(s): C er.aaent or OTea�orary 1 22 0 Sigoa�e ofCerafied eIICa t Dam
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7.Is this a repair to as existing wel@- •awes or mfro ISANCAC 02C:0100 or ISAbrAC 02C.0200 Will Cgraa,mrsm+Smndv*m+f der•a c
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veprrtrcorder 2lrenrmissecitonora>rdzelraeEofflGsfmsi nSal diagramor'addlionalwelldetalk
&For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional vmU constructim iuf
won,Doty 1 GW-I is needed idickle TOTAL NUMBER of wells. (add See Ovee m Rem Box}You may also attach addmmd paim ifnecem
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below had surface: 0 O 0 -( )
Submit this GW-1 wit)ria 30 days of well couqktios per the fellnwiag:
For ftle we&list all depth if4bv t(maple-3@200 mid 2@10V)
24m. For All Wens Original fours to Division of Watts Resm=w.(DW
10.Static water level below top of eashg 1, 10 (ft) lemon Pmce.ing Unit,1617 MSC,Raleigh,NC 27699-1617
IfcnmerlecritsdbovtaKse"+'
IL Borehole diameter. 6 {m) 24b.For Inketion Wells:Copy to DWR,Underground m Conw(A
Prograra,16M MSC;Raleigh,NC 27699-1636
11 Welt construction method: �,s A 24c.For Wads Sap j als and Oaejeg Geothermal Ream Welts:Copy tO
CLe.mom rOW'>-W aDap-14 010 COUUy eavuanmemai heal&departraeut oftthe county Where mstauea
FOR WATER SMTL Y.WELLS ONLY: 24d.For Water Wells redo' over 1 GM. t).DWR,CCF'CI
13a.Yield W,.* fl7stlrod of test �' Peimit Progam,1611 MSC, NC 276 1611
13b.DW,&.don type: 1 i Amount:
Fona GW-1 North.Carolina Dept ofEamomm =d Quality-Divisor of Warr Resaaeees Ravimd&:6=24