GW1-2021-06681_Well Construction - GW1_20211007

SELL CONSTRUCTION REDO, (�G'W 1) For iubwnai Use Only:
L Well Contractor Inforantion: -
L S
Wen CamacturName Ftit)M Ter DESCRUTION
3 536 1
o R 32D
NC Wen Co aea=C.atifi=dmNumb= (fir O 1 Z�Z R &
{ � {� � 3 l)l• ��1[`�V ODTEBCASIlYG : wells ORI�VYtt ` .-:•: .
To meMatsa 720CKLq= I MATEZUT-
m.-_
CompneyNamc
Qq ;1SIIVNffitCASQIGOHTO8Q76
2.Well Coastruetiou peamit S:'PR J'?ot 6 � o 15 (o 0 mum TO ,•, aas�rreL
auapp �v1G 1 varimrS�� —f.! 5 7 .'�/'r im r•� rt.
3.Well Use(Chaff well me)- $ K ;n
Witter Sappily Well:
❑ FBpM m +WAMXM SLUTS=
OMuaiccipaaUPubllic ft. S hL
ft
l7Ca et aleMO/Cooling SUpply) Aftsdeanai water Supply(smgie) 8
❑Tndustrisl/Commerew C&dd=fW Water SupPiy(steered) I8 t$ttNT1
DWells>1 000 GPD FROM TO MATMUAL taMLAcZM3Wrt "sa ioMCr
Non-Water Sapply well: % 23 tzNea i- {
OReeovery & ft-
h action well:
oAqWfer Mmundwater Remediation
❑Agt:iberStasage �, Barrier snrIDrGF VALre ¢__ _ A ::a ri >'••�•.F
MATUMAL II►�A�fra
DA4uifer Tast •❑SWImmater Drainage $ ti
Ol it l Tectumlogy ❑Subsidmx COUfral fL R
Oti(Closed Loop) OTraxr 20 DRII idNG LOii ateai 6 additmmat s>>eati'it - _ ,.
oGeoshmat Retum) 00tbar(oglain under 921Ramadm) FROM To Dec x „yi.ee .k
$ &
a Date Well(:)Completed: ef-Z I—M Wen M# ti:
52I.Well Lockdom -
Jc,t 1 �o6ti►- R s
M9(ifs) $
1'L� �Gi rk Q,, L ft. A
P*siCdAd&vmCit =d* tz iz
CY Pzcel Idendficati=No(PDQ)
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees:
Cifaall field,one is s�imt) ' 22.Certification:
3G� �.1.• 3� x ��' 5fS ' .�► .. WMao
6.Is(are)the well(s): APerm mum -or Mempo,=7 1 3 70 ' s ea Dm
'i BY�8�8�1�+.IhuebY�r���/�frr�sloaun�seoc�oor,dm,x,.mr
7.1s this a repair tD an esistiug well:' 0xis or 15AArAC 02C:0100 or 15d1V=02C.0200 Weff Coubuetar S and data aW
lfdda @a rqu[r�II ere bm�>�aaoar�eaarr Ravi and the�m�ro:ofthe �d+fs ieamd hm brmpmvided m der:�awrio.•x
nparravdtraDJl rrmmissaeffon oraR dubmd<ofdasfarm.
23.Site diagram or addifionalwen debdir.
L For Geopcobe/DPT or Ciose&Loop Geothermal wells having tite same YOU may use the bade of this page to proVine additional well omsttuctian h&
ooastntctiaq Q*1 GW 1 is needed Indic kc TOTAL Malilt of wells. (add'See Over'in Rem BOXI You may also s additional pages if necom ty.
drifted-_ '
u X SUBMITTAL DiSTRUChONS
9.Total wen depth below land sarfiew ! '
Foraadrrpls mv&bar afT dqx*ijdffawa(a=9ie-3(aj200'and 2�I00� ( � Submit this GW 1 within 30 days of well tomgletion per the foilowieg:
10.Static water level below top of eammS: U (fL) 24s. For All Wens: Origmd'form to Division pf Water Resoumm (DW4
$warertesrlsa46aneaabr��ve/',+//y (m Processing Unit.1617MSC,Raleigh,NC276994617
IL Borehole dnmeter. ✓/v gym,) 24b.For Iniection WeIIx Copy tD DWR,Underground iajwbm CouW(n7C)
�1 Pragram,1636 MSC,Raleigh,NC 27699-1636
12.Well contraction method:_ ZA a M — A re
CLe now.r C"direapaeb,ee) 24c.For Water Saeaiv and Open-Loon Geothermal Return Wells:Copy to the
oamty environmental epartmmt 01 The county weemftled
FOR WATER SUPPLY WELLS ONLY:
24d For Water Wells 99%teing over 1 GPD:Copy W.DWR•CCPCUA
13a.Yield(gpm) /0 Method of test Permit PrDgem,1 11 ,C 11
13b.Disin6xtlon type Amount: O w
Form GW-1 North Camline,Depart—ofTmv==mW Quality-Divaiea of W=r Res== Revised 6.6.2018