GW1-2021-07074_Well Construction - GW1_20210915

VULL CONSMUMON REM (GW-i) For rim Uw onl �.
L Well Contzaetor I1nformation:
•� A I�X-cc r,cl t:� 4aA .14.WATERT.OIt .. _
WeIICo aemrxame "~ ` 1 Atom TO mm"M,
ft ft-
NC wen e c s xn SF. rOz`)�rF�
P
CC"' ]SOU•lERCASJNG .multi ,*k&ORIdI�
n l �4,>Cs-or FROM To DIANUM i MATAtIAL
f� t: ft m
�N `" _ »
�1 dAG IP M CA31rI(i OR TIIBArIG ar :. p.S
2.well Construction Permit#: D 7/� 1 W PROM TO mensrM 71111CINNIXIS I ers331Mt
Ltsr all app%mbk rrll amanvcffanpotmtrs A&WC ComV.&V,Vanwxr-ue) -} ft 6j ft 5 7 Y hL I Tgr t K.
3.well Use(checkwa ate): st ft m
Water supply Wen :17. m.
FROM TO ~DIAN3n= I"SL4CYTSI2R'...,.1ffi! MA1lRiAL
❑Agriculba al ❑MuaieipaUPublic ft it hL
❑Geoffiennal(HeatingiCoolmB Su)ply) -4hmdential Water Supply(stogie) g, fa im
CIadustrial/COmmacial ❑Ressdennal Water Supply(shared} .. L GROUT y s _; •_':':::;,:
-0krigation OWells>10000OGPD FROM To MAT> tldL EaVIAcE®rrMSIRM&AMOUNr
Non-Water SupplyweM R lip0 R
❑Mmitoring ❑Recovery ft ft
Infection Well: ,
ti ft
❑AquiferRecharge ❑Groundwa3terRemediation
OAgmfc r$meagre and Recovery ❑Salanity Barrier FROM
SAPID/Qt TOT-
FROM To 1tfAT1ZtIAL � -^n�r.►caM�rrMsaeD .
DAquifrrTest ft ft
ObTerimeotal Technology ❑Subsidence Control ft ft
OGeothetmal(Closed Iaop) OTracer =20'DRIIdMGLOG aaesha8diaaoilahe 'it-" ,
OGeathermal(Heatinp'CoolingRetum) ❑ en om ( under#21 Remadm) FROM TO DffiCRVI101t
ft It
4.DateweKs)Completed: q-3-2l Well ED# ft R ak,6. bt7cre.t-t- C o
51.Well Location: R ft ,mow
�w ft S v
F�I W W Name Fae tp ID#WSW lieabk) $
ft &
Ntyri*IAddzm aly,mdTsp - 0,r 0 u,)'
2L RZMA8S5:
Comity Pmccl Id onxe.(PW
5b.Latitude and longitude in degreesfminabdieconds or decimal degrees:
Ctfwa field,one hdbug is ) 22.C Mcatio
6 I5(are)the wen(s): ermanent -or ❑Temporary V signature of Catificd 1VeitI
oo Date
� Bysgnbigdffsfor»;IhaebyeetnfythatdtemeII(:)wan(rite) --dstaoaorr8aeaeW&h
7.Is this a repah•to an easdng well:- RYes or i0f o ISAXCRC 02C*0100 or 15AJVCAC 02C.0200 Well Cotuv=ffm Stmrdmdr amf dtata copy
Ifdda it a rapdr fig on kmm veil coot mcdon mfornraaon and eplafrr the mnor of tlr of this record ha bem pveded to die well owna-
:rp�r ceder f`21 remmisseeffon oron thebaagfthirfarm 23.She diagram or addt4onal well detaft
8.For Geopaobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to'provide additional sell ooaahtretion info
won,any 1 GW 1 is needed.Indicke-TOTAL NUMBER of wells (add'Sce over'in Remarks Boxy You may also attach additional pages if necessary.
dnUed 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20d ( �, Submit this GW-1 within 30 days of well completion per the followft=
For mulupk welts lfsr all arepda ff&ffvvn(=wqA-3@200 and 2®100')
10.Static water level below top of 24a. For All Wells: Original form Ito Division of Water Resomm (DWR�
10.St �abow rue o�- �. (R) lihnnation Processing Unit,1617 MSC.Raleigh,NC 27699d617
rwau1L Borehole diameter. (m) 24b.For Infection Wells:Copy to DWR,Undaground Injection Conhol 911IP
Program,I636 MSC,Raleigh,NC 27699-1636
12.Well construction method: L`o A 2 jn4 A 24c.For Water SnDIIis and O�Looir Geothermal Return weDd:Copy to the
CLR me-,-toy.ceW duvapas%etc.) cwmry envuortmentat neaten department of use covaty Wm3e
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Drad dw over 100.000 GPD:Copy to.DWR.CCPCUA
LIL Yleid(gpm) Method of lose / Permit Program,1611 MSC, 11
I
13b.Disinfection type: I TIA70 Amount:—. - o Z
Form GW I North Carolina Department ofEmitonmeatel Quality-Division of water Res w= Reviwd 682012