GW1-2021-03209_Well Construction - GW1_20210625

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❑ OR ddeatiai Wab,Supply(sh-ed) -
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5b.Latitude and londede ia! atestseconds or decal degrees:
(ifweIl field,am 1aebi is ) 22.Certmeadon:
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6. Date
Is(are)the well(s)�er ine or DTemporary
BysZ=WdzsfbmIhaebyoertifyr d=dxwj(s)was(mm)mmnramdr7tn—dm--
7.Is this a repair to in eiisfing •QYes or )+,o ISA NCAC 02C:0100 or 15ANCAC 02C.0200 well Cpstsnacthsr$mtid®ds apd that a cp.
Iftldsisompafi:JWoralvavrnwdlCm WCfF=htfonWAmWdCP&aftMe=weeofthe ofthts,ecardh= empmwaai*dwe xowner.
r9atr order A21—is s setafart i'en ba�of tltfsfarm 23.Site diagram or additional well detallx
Yon may use the back of this page to provide add�offi1 well ao�m irrfi)
S.For Geopa obeNPT or Cl p Geothermal Wells having the same You
Over'in Rem Bmc�You may also attach addffinzW pages ff Dtxt�sary
consuuctitm,only 1 GW 1 is bulic'ate TOTAL NUMBER of wells
dnIled: 24.SUBMITTAL Il�I.STRUCTIONS
9.Total well depth below Iadd b A) -1 within 3
Snbtnit this GW0 days of well completion per the following:
For a=4*wells Art all t(e=mip1e-3@a 200'and 2@100) i
24s. For All Well= Ongmd Sotm to Division of Water Resources (DWR,
10.Static water level below Up of. L 0 (ft) bfzmrion Prot sing Unit,1617 MSC,Raleigh,NC 27699.1617
Ifraarkvd is,abomcmft•m r'
24b.For In ection Wells:copy to DWI;,Uadergmuod bjectioa Control(IUC
1L Borehole diameter•. hMrdM 1636 MSC,R NC 27699-16M
11 Welt construction meths o 71 n 24c.For Water Se aad Gmffiertaal Beaara Wells COPY to th
(ie auger enemy ruble direetpa: ,eRe i county eavaenmenCdl heahh k offfie eamiy when mWied
FOR WATER SUP'PI Y IIUS )NLY: 24d.For Water Wells Dredaeim¢over 100.t100 GPD:Copy bo.DWR.CCPCUt
Peaait Ptog=2,1611 MSC,�. NC 27699-1611
LIM Yield Method of test
13b,Dismfeetlon type: Amount !Z w
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Form OW-1 North Camyma Dapa hnew ofFinaom=mI Qm*-Division of water xmsaases Ravised 6.6.201
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