GW1-2021-00858_Well Construction - GW1_20210404

WEU CONSTRUCTION RED ffi l) For ldemat Use Onty �.
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2.Well Contraction Permit# �: To mean'
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3.Well use(cheek weft ase): -
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Water Supply Well:
FROM TO t DIAMSM I SIATSEM Tom. IMATt3tL�L
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oGeodmnw(Hemft&V4o&g Shy) Water Sup*(sidgie) R
ohidusbtaUCommettrnl Water Supply(sb—d)
WeHs>10 000GPD FROM TO I Mr►rReisi. BMFzwc�rr oDaeutornrr
Non-water Supply weQ: QR 3 R
OMontming ORecovery R
Injection Wem
13A4mfa Recharge DC nmdvmtEr Remediation ELfs h dh'k,
OAquE%r Storage and Recovety OSalidity Banter FROM TO I MAT OUL PLACRAWr !
OAquierTest QStaamwaWDiainage R ft
oExpetmtmgl Technology ❑Subsideme Coetral R R
CC— al(Closed loop) OTtaoer '3aiDBII.LIlHG LONG. aii ibb&&N`
oG�mal(Eeatmp/Cooling Rd= DOthe{(edam udder#21 Remarks) FROM To D F ,aah+erx each
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4.Date Wefts)Completed: Z/ WeB IIJ!! tz & .
Sa.Well Loeadon: R R
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ca a Parcel I oaNe(?W)
5b.Lati:t &and longitude in degrees/toinatWseconds or decimal degrees:
(ifwell field.one b0m is swat) 22.Certffication:
31, - 32' I N. AL 12' ' W W
6.Is(are)the weRS). OPm••ft t. or OTemporar9 e,a �u ' Side4wa,ewculcom"Taor Dace
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1lymgdtgdtafont;lhoeb mofy Zhu the we4s)was(were)owavre:mdbtavaotdm=Va
7.Is this a repair to an exbtieg weft:, CW s or fWo 15A NCAC 02C:0100 or 15AACAC 02C.0200 Weft C 0ruc at Sm dmdt and dar a cop
If dds is a rq=k fiII otd bamnrVeil*=MAW=fi#bnm0m&=mid emlmtri the naaae ofthe of dds temidhas Gevt provided m she weQ orazv
trpatr ratdo 21 nmtants scratch or art clue hmaEof thafarai 23.Site diagram or additional well demos:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells havmg ft same You may use the back of this page to provide additional dell conshuctsoa into
conswmdon,Duly 1 GW-1 is'needed. 3ndicdte TOTAL NUMBER of wells (add'Sm Over'm Remmics Box}You may also attach additional pages if necesssy
drMed C J/�y 24.SUBMITTAL 1"MUCTIONS
9.Total weft depth below land mrfine: I a 1 (it)
Submit this G -1 w
peraadrlpte-ells Sat aft dg d-if&ffi a(aemwk-3Q200'and2@100� Within 30 days of well eompktioa per the following:10.St m&water level below top of easing: V (R) 24a. For All Wells: Odp ad foam to Division of Water Resotaoes (DWR,
at o.e Y b>tomaticn Processing unit,1617 MSC,Raleigh,NC 27699-1617
1L Borehole diameter. t/4 (m) 24b.For Iajectoa Welts Copy to DWlt,Underground bgeceon Cool(IUC
Program,1636 MSC,Raleigh,NC 27699-1636
11 Welt eoastrmfin method: 0 a r •�'
`a 24c.For Water SnaDls and Oaca-Loop Gcafficrmal Retara Weft Copy to th
(Le.04M rofy,cable,�P>�,�) county environmental health d ofthe county whore tt�tled
FOR WATER SUPPLY WELTS ONLY: 24d.For Water Wells DE243ftover 100.OW GPD:Copy to.DWR,CCPCUj
13a.Yidd(gpn* CO Method of test: /1 !Y, Pail Pmgram,1611 MSC, C V6 99-16I 1
smt'e m Diethon type J_R-T '� Amount:
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Foau GW-1 North Caroliaa Degattam=ofEuvnoaumcital Quality-Dimon of Water Reumm Rswiod 6.6-201