GW1-2021-06774_Well Construction - GW1_20210809

WELL CONSTRUCTION IF M-1 For Internal Use ODiy: .
1.Well Contractor Information:
1 3 A L a_r .14.WAMRZONES.. _
Wen ComtaomsNam FROM TO DFSCRIPIION
& fR
NC Well Cordes Cneicsfim Nmaber I&ODUR CASITIG for mnitirmsed Wells OR IBM
N G w m 3 w. 3 r+n , _ 6 FROM To DIAmm IZltcsavass MATERIAL„
R R is
Company Name
D ^ p 36.Il�MMCAMNGORTIIB7NG( •....•. � -
2.Well Construction permit#: �1 L.2 Q 9 G FROM 1'O DIAbMfBt T l�AIAtiAL
Lsr all applicable weQ earesnsreuan permits WC Cototty.Smfe Variance,etc) R % R 51 dr i Th r k— ?L'
3.Well Use(cheek well use): R R in.
Water Supply wen f17sclisBrr
FROM TO DI4WM SLOTSEM I8R30405 MATERIAL
OAgrioulttual ON[unicipal/Public R R in.
❑Geothermal(Heating/Cooling Supply) Evidential Water Supply(single) R R in.
OkxlustriallCommencial OResidential Water Supply(shared) IS.GRODT
VIrrigation OWells>100,000 GPD FROM TO MATERIAL EMPLAC@tSIMrPM=OD&AMOUNr
Non-Water Supply Welh
OMonitoring ORecovery R R
Injection Well:
R
DAquiferRechalge ❑GroundwaterRemediation R
>19.SAND/GRAVBLPACK d" M* _'s:': :; •r-u 's';a: J:: a'S
OAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL ? rMpTecl rl'MarHeD
❑Aqui£erTest OStormwater Drainage ft R
DFapesimental Technology ❑Subsidence Control R R
OGeothermal(Closed Loop) OTracer "20.DRIIS 1NG LOG saac3 additional if ""s ' '::>;:i.
OGeothelmal(Heatmg/Cooling Ram) ❑Other(explain under#21 Remarks) FROM To
DE6CIiIPTiox cobq arVfaek do
R R
4.Date Well(s)Completed: 'y Z Well ID# R S. .
59.Well Location: & R q!�
v R
i n h i JL
Facflily/Owm Name Faeffity M#(ifapplicable) R R O
aqlcev
Physical Addtes%Coy,and* ' , fL R \ �3Zi'Jil O vlllt
d LA.lr r 21.REMARSS b u;�;
County Parcel IdeatificaQon No.(PM
5b.Latitude and longitude in degreestm Linatestseconds or decimal degrees:
(ifwen&14 one rat/long is svfficielot) 22.Certification:
(o' 3l ' 33" N b ' 33' W
6.Is(are)the well(s): ermanent o OTemporary / 3 L 0 ' Sigoatme of liVeIICogacoor Dane
BysignmgddsfomI hereby eerafythar the w U(s)was(were)cromvuctedbracaordmroewith
7.Is this a repair to an easting wen:, C3.Yes or l<o 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Consimretfon Stwxbnb and that a copy
IYldds is a repair;fill our brown well cmavuctf bfornamon and explain the nature of the of this record has beenpnwtded to dw well owner.
repair roller 921 mnarksecr/on or on the baz E oftfusform
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop thermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW 1 is needed. 'lnc icite TOTAL NUMBER of wells. (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled. 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �` r (fL) Submit this GW-1 within 30 days of well completion per the following:
For multpk wells hst aQ depths ifdrfferem( le-3@200'aid 2QI00')
249. For All Wells: Original form to Division of Water Resources (DWR),
I0.Static water level below bop of ( ) Information Pig Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwafer level f$above eostng.KLw"+--�/
11.Borehole diameter. ! 8 {in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(NC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: D�3 n' 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.-ism,ratuy,cable,daea per,etc.) county envu onmental health department of the county where mstaucd
FOR WATER SUPPLY WELLS ONL : ^ 24d.For Water Wells rode"' ovei 100.000 GPD:Copy to.DWR,CCPCUA
13a Yield(gpm) l y Method of test
r r Permit Ptogram,l 11 MSC,Rialeigh,NC 2 699-1611
13b.Disinfection type: Amount
Farm GW-1 Notdr Carolma Depamnent of Envuoamewai Quality-Division of Water Resomm Revised 6-&2018