GW1-2021-06177_Well Construction - GW1_20211025

WELL CONSTRUCTION REC,Q v (GW-- For ixlftrnai use oar-
1.wen Contractor Information: -
L • S LEI 4-AJ 14.WATSRZOrmmw
wen 11BOM TO Dl ]MON
300R 00R
ft ft
NC Well CatificidonNumber 1S�,OD7ERCASING ftrixm1 welia ORLINE ff
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�lrN/ ft ft is
Coa"WName
2.Well Construction Permit ft:_eS 0 (� 5 I :1 'IIV CASTrrt:OR G ..•.tiiQm:l :�. :•;TO I DlAtuziat 1 73MCKN1135 nssIlm:si.
Ust aII appBoable UWE aeraaaedo»p"VWX tie talc Cororty.St^yarfow.era) -1• tt 12d R• (q� fo. K t YL,
3.well Use(check well use): $ ft ;n
WaterSup*Wen:
FROM TO - c DI MErP3 SIXSEM TRKWUN ltA1?RiAL
DAgicuhtual DMunicipallPublic
DGeothennai(Hea#*CoolmB Supply) earial water Supply(single) ft ft hL
Dlndust<ial/Commereial CResidential Water Supply
Jk
❑Wells>100 000 GPD FROM TO 1KAT83 LET. WCgACZMZRrIbSJ80D&AModM
Nob-water Supply Wen: .n 3 tt („
Dblgnitoratg DRecovery R 4t rI.
ection W
& ft
DAgmftirRectimp OCnotmdwaterRemediation
OAgWfrt Stowage and Recovery DSalinity Barrier !(RtAVRL PACE d :r max,• ,: •,_s ad;��; t;
TO I MATERIAL I IMMACEMM MlMD
DAquifierTeat ❑Stoimwaft Dnktage & ft
OB9aimental Technology ❑Subsidence Control ft ft
13 al(Closed Loop) ❑Tracer ==DRWMG1DG XftxW"ohala6leei`ft_" :nir
DGeothermal . Retina DOtlr� under#21 Remarks PROM TO DOCt VMN aw -Staaa : :ao
it ft
a.Date Well t h,—
Ss.wen &Location: - ,� •
ANM, mM h ft
FamlityAlw=Name Fly M#(fappfi-hk) ft. 8
RECEMItY
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Pl;ysiul AdrheaR City,and Tp tt tt O C T
ARKS
Pu*-1 Ideadfication No.(FIN) lnfarrrlatlOrl rQc
5b.Latitude and longitude in degrees/mmntesiseconds or decimal degrees:
(ifwan ffW14 one latilm a e ) u 22.Certification:
.3 6 DT W
6 Is(are)the wen(s). DPermanent or DTemporary, 4 5 0' S*aMm . � Date
By stVrbig+htrform 1herebyevo dot the wrll(t)waa(w,")eeroatcaedorammdoorwah
7.b this a repair to an existing well:-, f CWi s or e&&- 15A NCAIC 02C.0100 or MAIN=02C.0200 Flea CV—uc*n Sa Wm%*ad mat a copy
. Ab ira 0Vjx* er<hrowt w11 emammtlar b oraaarron mad sptabr zhe.mRoe ofb4W of rids a eeord 1,m bear ppovPdsd m rho .ell anarr
repati aradii01 teamissaarar oron thebaaEoftlatsfona Nq
23.Site diagram or additional well details:
S.For GeoprobeMPT or Closed-Loop Geothermal Wells having the same You may use the bards of this gage to provide additional well coosmrtion info
oonstntetion,only 1 GW 1 is-needed.Indicdte TOTAL NUMBER of wells (add'See ovee in Remarks Box}You may also a8ach additiond pages if necessaty.
dulled: //+ 24.SUBMITTAL INS'MUGTIONS
9.Total well depth below land surface: Z ft
For mu& „�, (t*) Submit this GW 1 within 30 days of well completion per the folio
p� daprhr►f4knw(==vpk-3@200'mrd2@100� t+ID�:
10.Static water level below top of cashtg•. & V (fL) 24a. For All Wells: Original form to Division of Water Resources (DW4
rwaar kad it above .1. Wormation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. G t( 8 {m.) 24b.For Injection Wells:Copy to DWR,Undergotmd Injection Cool(RUC)
Progtam,1636 MSC,Raleigh,NC 27699-1636
12.Wen construction method: l C 04 h„ A rY'
(Le.v*c;wtay.c.dk apask etc.) 24c.For Water SuPM and Omen-LooP Geothermal Return Weft Copy to the
county env—mmmenM health depattmertt or the�vMere insfalled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells grode I over LO��0011 GPD•Copy to.Dwl,CCPCUA
Permn grogram,loll MS lei 2769��i11�
13a.Yield(ppm) Method of test: rY' j
13b.Dielufection type: Amount: I Z
Fotm GPI-1 North Carolina Department ofFavaoommotsl Quality-Division of Water Reso=es Rrdaed 6-&2018