GW1-2021-07462_Well Construction - GW1_20211006

WELL CONSTRUCTION RED' For Internal Use Only: �.
1.Well Contractor Information:
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wen Name C'€\ FROM , TO IDFSClttP1ION
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xC Well Camtisc'mr QkN tz
CeaifiatiOaNnmba
Newman Brothel's Inc. 7uomMcasflvG rae .:�ta ORL11�R
16768 Hwv 268 W FROM TO Dreaarss a MATi*arAr."
Elkin,NC 28621 =3e4VMMCASMORTUMNC.
2.Well Construction Permit#- To VIAMMM a ass ess,mtret,: :"�
Ztnalra fih2bk+aellamsnvcvlanperantts(-MCCoway.SmsSYanwwe,ert) + 1 &164 ` S7 in.
3.Well Use(Cheek well user $ R im
Water Supply Well:
FROM TO DIANN= " SMSM TEMCO 6 :MA1lattAL"
&
Agrrcuhtael OMunicipaUPublic tt in
Geothe=al(HeatmWCoohng Supply) OResidential Water Supply(smee) R ft in
OlodusaWCa®mercial OResidentW Water Supply(shared)
MG LOUT
fl OWeUs>100 000 GPD FROM To MATERIAL ENRACCUMMAZIRODa:AMOUNr
Non-Water Supply Well: R Z3 R Al t
Gl�imibaaing ORecovery R &
Injection Wem
OAqu&wRechse OGrvtmdwaterRemedisdon
rafc Stotage and 19 SANDlGRASzL PACE
OAg
Recovery Dial nityBarrier FROM TO MATERIAL n►trlwC�KRONTr
OAquiferTwt DStormwaterDrainage $ R
OExpetimmmal Technology ❑Subsidence Control iZ &
OGeI(Closed Loop) OTtaar =2tL DRII.LIlHG LOG albei►�ad�it�ls>i 'if
OGal Meatmp�Cooling Return OOlha(explain under#21 Remadm) FROM ro
� a x aihaeh :e1e
R 8
4.Date Well(s)Completed: Well ID# &
5a.Well Lotatiow. ft'
LLI i S A, Pa Y rn 7 U-C' &
FadUyq.=Name Facgity1D8(ifoppliwble) $ ft
(5 21 " C ecd Or __10 re,t-z
P*sical Ad&v4 CAS:cad Zip t tt.
Cooaty W✓ Patrd kkatiticstioa No.MN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
of-a Sold,awe h lm is ) 22.Certification:
6 U(are)the well(s). �rmanent or OTemporary /O"d I sigoanae afCeetiSed'. I Dane
s
BYsfBws d0lom 1 hemby evV5,Av dw weQ(s)vw(wens)oornvucodftacwdm w vfth
7.19 this a repair to an existing welt- ❑ ;s or Ma— 15AAUAC 01C:0100 or 15AArAC 01C.02M WeB Covabueffat Srmedmdr mai dwr a copy
if*,isargaatrfigmibmmweamemuawiifmwavorandaplabithenaa Tofthe ofthismwdhm&mprov&dmAevrllOmv-
repmFr wider t`21 xmmbrsecoon or an*e had ofthisform
23.Site diagram or additional well detalis•.
8.For GeoprobcMPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
comtrtretion,only 1 GW 1 is needed.Indicke,TOTAL NUMBER of weU& (add'Sce Over'm Remarks Box}.You may also saaaeh additional pages if necessary.
drilled. 24.SUBMITTAL 1NS'mucnONIS
9.Total well depth below land serfaee: /Q 2 , (ft.)
For rmlatpk wells So ag dWk if&ffirew(amapk-3@200 w d2®1M Submit this GW 1 within 30 days of well completion per the following:
y (R) 24a. For All Well: Origmal Sons► to Division,Division,of Water Resmuces (DW4
10.Static water level below top of easing:
1j���abor +• lnfomration Processing Unit,1617 NBC,Raleigh,NC27699-1617
1L Borehole diameter �d gym) 24b.For Injection Wells:Copy to DWI,Undagwnd bjection Control(RUC)
/1 Program,1636 MSC,Raleigh,NC 27699-1636
i2.WeR construction method: y�aka — /�,Y
Cna�raeQy�dim P��) 24�For Water Sa I and O n-Loob Geothermal Return Wtd�Copy to the
cormty mvm:arm�pUtment or me oomuy wnM mimed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Md&cMoven 1 GPD:Copy to.DWR•CCPCIJA
13,YW(gp,) � t Method of test: ,�,, Permit Program,1611 C," C 99-1 11
13b.DisinEeetion type: T Amount:
Form GW-1" Nor&Carolina Deparmsew ofBmonmcaW Qaalily-Division of Water Pus== Ravened&&2018