GW1-2021-00353_Well Construction - GW1_20210127

WELL eON,STRUC'I`I©N RED (GVV-1) For Internal Use Only `�^
L Well Contractor Information: "
.14.WATERZ01US_.
Well Conoxiam Name FROM To @ DFSC'EMON
3535 �D� R a�DR
NCWeUCo-6-tarC ekitimNmaber a Ui7TERCTA.4IIQG 5amulfi edwells ORI.I[IItR d
Q.• ' FROM 9 DIAMSPF3 ! MHCKN= MAMMAL
R fG is
Cosxi;iaay'Name
I 1(�II�IlHSR GLSII�IG�OR
2. ,_:
Well Construction Permit#: V rtaonc TO 'VMmi c •�CMUM MATERIAL
Itsr aII applicable well amatruetlon per»6tr(ze U1C Cowuy.Srm4 Yarim+ee etc) 8 5 ft- 5 7 V m i c.
3.Well Use(check well use): R ft m
Water Supply Welk 'J SCRSBN:..
FROM TO DIAMEM I scars= TIDCDMSS` MA1IItL4L
OAgiculdaai OMtmicipaUP he ft. ffi in.
OGeotbe®al(HeatiogCooimB Supply) id..tW Wt.Supply(single) R is
❑ladusftwcommer W ❑Residential Water Supply(shared) 18.QtOi1T
13 , []Wells>100,000 GPD FROM TO MATERIAL SMPIACCHIMMEMOD&AMOUNT
Non-Water Supply well: 0 R 3%LAj ekle i +•�-
❑monitot ng ❑Recovery R ft
Injection Well: rf'iz►r �
fL ft
❑Aquifer Recharge ❑Groundwater Rernediation
-
❑Aqui£er Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL 1 1 IMMACEMIMM IRGI) Y.
OAquifer Test OStoimwater Drainage ft
❑Fxpaimental Technology ❑Subsidence Control % R
OGeothamal(Closed L00p) OTracer =20 DRnAUNG LOG airsch sddiaoasl stieets if—e _n—E =
El Geothermal(Heating/Cooling Retam) 00ther(explain under#21 Rem dm) FROM TO DESCRIF.MN color,hs&hm,w9fr ,A -.eta)
4.Date Wells)Completed:_t—20—21 Well ID# &
Sa.Well Location: & ft
j
j �.
Fac,lity/Owaa Name Faci1fty MA(ifs-bu) p � & fit.C�e5fnG.f Cer? ,k Aj tfa[ctnf.e{r/Wf . fL &:
ftsioal cc tt.City,and Zip 6 t;v-C G—rr-..i,C- .,�,,, R
.2L:R39&] S:
County Parcel IdeonNo.(P�
5b.Latitude and longitude in degrees(mmntes/seconds or decimal degrees:
(ifwell fiold one ladtoag is suuffieieot) 22.Certification:
N 530 a3 5s W
6.Is(are)the wen(s): 4-manent or ❑Temporary G' Srgnanue eIICo Date
i i r
gysizn tb d-jb tt 1 hereby,a7i;D�y Mir the-'el )was(rise)masa ra=d,3t acw,dz xw:wit
7.Is this a repair to an existing well•' •Oye's or )(No 015A NCAC 02C:0100 or 15ANCAC 02C.0200)FeII Cgmriaction Stmzdards am3 d=a cop
If this is a ts�,ur fiU ot6 btowtt well eomnvciYon nrformators aced e h�(� 'f'2 ofmis mcoidhw been pme&d to the.a owner
mpztr ruder 921 remmis section or on the back ofthis faun i
23.Site diagram or additional well detar7s:
8.For GeoptrobdDPT or Closed-Loop Geothermal Wells having tiie sariie ,-,You may use the back of this page to provide additional well owstniction info
construction,only 1 GW 1 is needed. Indicke TOTAL NUMBERiofyklls.-' (add'See Over'in Remarks Boxj You may also attach additional pages ifnecensry
dulled 24.SUBMITTAL INSTRUCTIONS
t
9.Total well depth below land surface: )4 Q (ft) Submit this GW-1 within 30 daps of weII completion per the fellowittg
Forandtiple we&Ast aDdepda�d�l�pk-3�a 200 mtd 2@1M _
10.Static water level below top of cashW. (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR,
Ijwaier IeveFis above Darin&i6e"+' Information Pr Unit,1617 MSCS Raleigh,NC 27699-1617
l/ 24b.For Iniectron Weils�
11.'Borehole diameter. � `� .(m,) Copy;to DWR,Undergoumd Injection Coatiol(IiTC
nn
Program -.,1636 MSC,Raleigh,NC 27699-1636
12.Welt uc constrtion method: R a l 2 A.,-r
Cr a ow'*area pusk ) h1 24c.For Water SuPW and Open-Loop Geothermal Return Weft Copy+to tit
county environmen al health d'eparrment of me county canoe mstaued .. ._. _....
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells! roducing over 1 GPD:Copy to.DWR,CCPCW-
Permit Pmgram,1611 MSC,Raleigh,NC 27699-1611
13a'Yield(gpn* 50 Method of test
13h.Disinfection type Amount: 10
Form GW-1 North Carolina Dept ofEuviro�Quality-Division of Water Resources ! Revised 04 201