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GW1-2021-03197_Well Construction - GW1_20210625
WFJ—L QQNSTRUMON GW-1 For dal Use Only- " L Well Contractor Information " Well Nam FROM TO IDESt�lION i ( ft. IL ARC Wall C or Certification Number &OUTER CASV(G IdtltiR' FROM 170 DMMXM MdISR1Al. 1�► ft R is C=*WyNWoa 7.Well Construction PaInitft L-Gq D 0 13l FROM I TO I DIADEM= f *91mcwtim IJstanapleBmble veu anpamtts WC Cow Szam vbn=m=) -+1 1}5 ft- °` {?/Gr, rL.► 3.Well Use(check well used ft ft. is Water Sup*Well-. � 7.`S�l::. v<�b:: t:> .._:hu t:: :�;'::�k�%s s• z:,_-.c:; ��� # :FROM TO DIAMSF� SUMS'= ffi i ![ATRitIAt: ❑ It ft oc,eo&=W soy) `` Watx s�ppty(fie) $ ffi 0 MeddentW Water Supply(shaed) Ia GRc1�r fl , OWedb>100,000 CFD FFJ M TO MA78RIA3.. 3dMgUM Noa-WatWSv*welt: D ft. 2-1 ft OMenit g ORecovecy & ft injection well- #t r i 1 • '` ft l7AqufwRechatge O(imundwaterRemediation >1asAI Y$LPAt af" -:� OAgmfa Stump ants Rwova), OSalinity Barrier - FFA M To MexCfAL nitlFamwxw OAqudttrTest .OStomrwaterDramage ft ft OEveximagsl Ted adogy i.75ubsideoce Ctaoimi ft. ft. OGd(ClosexlLoop) 17T13eer =20 DBIISd1tG1.Ot' aetrsltaddieiahidsbiE lri&iift"- r ' ❑ram Rawer) 00dw(wgbin ter#21 Reuss} FROM TO Doi ,yin ec etW ft ft 4.Mtn wells)Completed: (i.Z 3 Zl well 1It# & ' — (�() So,.Well Location:: ft. W . Foofty/Ownear Name Facnkty Mg(ifappfieable) ftsiod Ad&ea%Ch•Y-drV ft & J 1.1 1 141 ZI 1S1MlABBS: . '. DVVR becton Canny Paccrl ldamffactionNo.M 5b.Latitade and longidade in degrealmk uteslaeeonds or deeunal degrees: (d'wen fiel4 eax is ate) 22.Cer tiom tr.Is{ar e)the welt(s):ffi'lrraansnt or DTemporary / D 00 } Signature,ofCaer �Vc11Cm:mmcros Dm • ByjiVa gdus fomIherebya7*zharhew4sj,em fwm)cmvumd&aoav doucev c 9.7s Phis a repair to so, vvaR CLI'es p� GlNa 15AIr—C OX 0100 or IM N1C.tC 02C_0200 Febi C ruou stag Smatcfaris and dtata cap lfrhts isa rqx&,,Iiv cad b=W uaQ W=v=d=bJornroIIotr and espltaYt the n=av of the of d&teaxidhas ban pradda3to the loa amen. •repabmderf21ymw:ssea en or onebrb=kefdifsfom 23.Site diagranterradditional well deft rls: &For GeoprobeMPT or©oaae&Loop Geofkermat Welk havingft sazeze You may use flee back ofilrs gage to p vvide additioaal well constroation info, consftucd ,only 1 GW 1 is Iaeei1ed. iadidte TOTAL NUM73Elt of wells (add'Sm Ove a in Rmarim Baca You may also attach additioflal Mes ffnecemy dtiliexi 24.SUBMITMAL INSTRUCTIONS 9.Total well depth below had surface: t Q { ) completion n Forasdtlpfe,.e&&a aa&prla#*Affi*—(--Vk-8©200'an d 2®100) 1 within 30 days ofweII mpletio Per the fellowbW.. 20.Static water level below tog of wag { ) 24s. For All Welk: Original farm to DivlSiaa d Vertu Rrsroaaoas (DWR, Boreho.y�>�isdbovenosh".race,+. hifarmatiaa Unit,i617MSC,Raleigh,NC27699-1617 1 24b.For Isiection Wdlt il. le diameter. t s l3 jm,, F ,1636 mcf Me`* 4 NNC 227699�-163366 C iz waR eoastraction method: O}:71 ^_' 24c.For Water nn OM Loop Geotharl d Batas X r COPY to tb (Le;engen;n,tasy edge,arectgush,Ott) �y anvtronm hea ' dgwkaeM cifthe cw*vmate Installed FOR WATER SUPPLY WELLS ONLY: 24d.For Water Welk gpdwm over i GM Pamit Progna o,1611 Raleigi,NC 276 1611 Copy DWR, � 23a,Yfetd(gpm) 3 Method of test r'�` 23b.Dhhhctlon type+.,.,_--H Z Amount: Foos GW-1 North Cacolma Dep a-w ofEwAronvacutal Quality-Divi of Water Resaaatts Raviwd 6.6-201