GW1-2021-05289_Well Construction - GW1_20210601

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p ;ag ecovery fz $ Po r+1-a
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4.Date Well(s)Completed: 5'�-1-1 Well M# & &
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5b.LatitaBe and longitade in dege/minotes&—nds or decimal degrees:
(ffWeen*A me k1low is ) � 22.Certifieatioa:
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7.Is this a repair to as eadsfing welt, •I3Yes or ftN ISAA IC 02C DI00 or ISANGIC 02C.0200 iieII Co rxcros+3t�mid Char a Cop.
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nrpas ra,do a21 rm mis seeffan Oran dT 6ar.4Olr&f— 23.Sift diagram or additional well detail
You may use the back of this page to provide addifioaaal well eonsbucQm imfb
S.For Geopttobe/DPT or Qosed-Loop Geothermal Wells having t same (add See ovee m Rem Boxy You may also attach awl pages if i sarY
mom,a*1 OW-1 is needed idicift TOTAL NUMBER of wells
dulled 24.SUBMITTAL Il�LSTRUCTIOPLS
9.Total well depth below land surfaces Z� (ft} Submit this Gw--1 within 30 days of wen completion per the following:
F,,-=&pk wills list all depth lf4%nw(=-Fle-3Q200'afd 2®100)
�J 24a. For All Wells: Origbbal fusm to DivisiCll of Water Reswaces (DWR;
10.Static water level bdow tap of c-i Z5 D A) I¢hnmation processing Unit,!1617 MSC,Raleigh.NC 27699-1617
I wowksd is a6m caift:rase"+'
/ 24b.For Infection weQs:Copy m DWR,Undergoan�d bajectfon Control(TUC
]LL Borehole diameter. / Ism) hvgram,1636 MSC,Raleigh,NC 27699-1636
11 wen construction method: 24c.For water Satml9 earl gOpe�n-Loom a anal Before WeIIx Copy tO th
CLa auger,ratsty cables daeetpnsh,�'.) cotamy eavffa®memfal health"" •"" 'of the COlmly where
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Oredneitat:over 100.000 GPD:COPY to.DWR,CCPCUr
PMMERograms 1611 MSC;Raleagls,NC:2/699-1611
vhL Yidd(gpm) Method of test:
13b.Disimfectioa type: Amount: 1 2 k--'
Fay OW-1 North Caro}isa Depatm>ent
ofEtrvisoommtal QtmhLy-Division of Water Res=m Revised 6-6-201