GW1-2021-04152_Well Construction - GW1_20210827

ELL eoNSTRUCTION REM fr GW-11 For hternal Use On1T: �.
L Well Contractor Information: "
.14 WET, ....wen Nam ZWK To nrs�a�ox
L+mi l , R R
NC WeTiCoohsetnrCatifiaaionNutmber iS.ODTEBWING he.iib � *dbj ORTD=
af
f FROM TA D7AM8T88 123C124185 I MAMMAL
Q 16.3IaTERCASRtIGORTUB�TG '"- _la=''.:w;•�.n'�:.:::�<;, ..
2.Wen Cen3ftdWn Permit#. 3 -l `'- 52- PROM I To i msIWIS r s Fssx�u,L
3lstoII app9aoble ved oevaarerlme peamftr t�We Comcy.SWA vmtmrcG eft) ( R R hL
3.Well Use(Cheek well an): R R io
Water Supply Well:
❑� ❑MunicipeUPublic FROM
To IL
DUMmat SUMS= TF ;StA1@tiAl,
❑Geod m W(HeaftnWC;oolmg Supply) OResidentiai Water Supply(smee) R R m
OI>zdushml/Cammeaciei ❑Residential Water SMAY(sham .18.GROUP°..
13kdzldm riur.11.,,1n4000GPD FROM 'ra MATERIAL
Non-Water Sapply Well: R R
nM eefio8 ❑Recovexy R R (�Aje&r
©A9� OCaoundvrater�edtaticn R R O ro e
DAgtriSri Stosage sad Recavay OSalinity Barrier From To I
LPACC �x�_ E ;_
MATSRiAL ZMMAC dWr3t> D
❑A9uiftr Tcst •❑Stonnwaser Drainage $ R
OB MtmGftd TWhndogy ❑Subsidence Control R &
OGeothtaDoal(Closed Loop) ❑Tracer -20 DBIId IPiG I:AG(zftc iddiem-1 s>sa 'R'"
OGeotht�el(H imB Rehm) OOther( ram tsndet#21 Rt rl FROM To axscxBTiox ,.vexes: :eye
R g
$Date WdK3)Conpieted: .Z 3,Z l well m# R R
'
Sa.Well Lodation: - R a® t�
`Rob�,ri" . 510Ykr Estal-c. ft. R ,��, V .�
FaabtY/O*'=Name F=-W Do(ifapptieable) R r R
Pk*daes City,sod4
V px �d R R
i 1 3ton Prov8$ri!iq �Jtlil
77
comty percd Weaffm8fim No."0
Sb.IAtitnde and longitude in deg rees/ninutestseconds or decimal degrees:
ofWan 6014 ODE is ) 22.Certification:
6.13(are)the well(s): a Permanent or ❑Temporary 4 0 S'S ofCatified WaII Dam
7.1sthisarepairtoan well:- •=is or WeirCsvers)ownvreemdne ,ddW qpy
e>osting �No ISANGlC 02C:0100 m ISANt^i1C 02C.0200 Well Cpncdra�avr Stmadadr mad davta cePP
f*Sisgrnpzfp ab.v—"do cW="= ffvvtpma apdcomme now.Ofhe of LOW remsdhmaewpvwideatorhevrlOndr.
xpab-raader#21 xearrisse eYaa or the b=k O1trvsform.
23.Site diagram or additional well dehft:
8.For Geoplr+obe/DPT or Closed-Loop Geothermal Wells Laving the same You may use the back of this page to provide additional quell constnxtien mfo
construction,only 1 G W I is needed. Iadicite TOTAL.NUMBER of yells. (Add'See Over'm Remarks Boxj You may also attach additional paw if neoeasary.
dried 24.SUBMMAL IlVSTRUCTIONS
9.Total well depth below land surface: 'y� (R) Snbrt this For Derrldtpls,re!/sHsteOdapeJa Ifrrra(ea�rpte gVo 2pp'med2�rpp� GW 1 within 30 days of well completion per the following:
10.Static water level below top of cesb : /00 A) 24a. For All Wells: Original form to Division of Watm Rssoeaoe3 (DWR),
f,a�kgatudboaeazra>$;acte•+/-�`/ cn Unk 161-7MSC,Rahagh,NC27699L1617
11.Borehole diameter. !7 1m,) 24b.For bdection Wen=Copy to DWR,Underground Inject—CoattoI(IUC)
r(� 1 /� Pmgsa�1636 MSC,Raleigb,NC 27699-1636
12:Weil contraction method: 11 t>1 Z w /-i Y,�—
ia.���,&redr %ao.) 24c.For Water Sno and�Opest�Loo�Gea�ermal Kettles WeDa:Copy tote
oouniy environmznrat steasm departatetnt of the
FOR WATER SUPPLY WELLS ONLY: 244L For Water Wells gggftdm over 1 GPD:Copy to.DWR,CCPCIIA
Da.Yield(gpm) Method of test ►- ra=Proms,! 11 MNC, 16 11
13bh Disinfection type: Amonnt w
?on1 GW 1 NW&Carolina Dgmtmant ofEnv==e=d Quality-Division of Water Resources Revised 6-&2013