GW1-2021-07465_Well Construction - GW1_20211116

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NEU CONSTRUCTION RE!QQ�(GW 1 For Intern se
1.Well Contmetor Informatton:
weaCoatraaorN®e ' O
��� I DOR' 6D ft •
NC wait eo��yseaor e«cfiemoa Nnm�ba�,/ - OUM Wigs OR LnM N .r.�r•.. -.
,�W1/ 11/�/_f:J•b'U/ ►lip FROM TO D
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Compe�Neme i
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2. it.
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Wen Comtevcdon Permit it. v� �' TWO: '.o ` FARM ' D7AMtlZs '•
LttdauappNeabie,eraaaravrcrre„psrodta��tdG eere�s veae>Kx erg •{- R 2 2 ft I LIle m 7ht et vfi
3.wen Use(cheek well use): $ & m.
Water Supply WeD: aJd;?""'L, i i .-sr•
FROM I 0= YffiC1NISS MATfWAL
DAViculturel OM ho }� {e,
DGeod=W(Heapng/Coolmg Supply) MRewd WSW Supply(ewe) R R in.
OladusbWCommercial Oitesidential Water Supply(shared)
000 GPD M To :
Noh..water Supply welt: fLNeer t
oM DRecovery fz
on R h
D Se DGrormdwater•Remadistion fZ
DAquifer Storage and Recovery Mabity Barrier r19.SANDlG4RAYJit PA ri .' •' t •K,
FAotrs ro MA �,�
DAquderTest •OStormwaWDtainage tt R
Dihtpafinentd Technology ❑Subsidence Control R fL
OQeothamal(Closed ) DTracer xsQ`DRIIdaTG•LOG adkth'liaelittoirititti'if ". it 13Qwtbamal Return ❑Other under#21 Remarks FttAM TO vzxM?pT10N
4.Date well(a)Completed:ILL i L web M# fL
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3a.Well Lotationt • R f
l~U�v R (L
FwftIQwe6 Name Fseft IN(�
applicable) ft. y R
i1• - j . R l
dal Add Cio,Bald Zip
fL
4 Pnoel idead&sdoa No.(YLd)
ffwep Ud,tam btgo longitude ) minntes/aeconda or decimal d egreq:
- `r J N 2Z CertIticatIoa: .
6.b(are)the wd(s); Drermanent or OTemporary
t,��a 818moae ofCer$fied, ell
7.Is this a repair to as e=istlag weR� ❑Yes or tI �'a�+BJb►+►�I r r Due
fJdua Lenpay,Fu p��w wau o ISANCAC 02C.0I00��0'c o700�jr ff 1J�w m �A
►Qpr toide,i�u 7 seeLlea Ot on a e. ." �d�,�l+s amo,V%%c o &* ,kv .amp
8.For Geo
pcobrlDPT or Qosed-Loop Geothermal wells having the same you�, oralcdditl well details;
drill construction, 1 GW l is•needed. Indicate T oTAL NUMBER ofwella (add'See Over'iri Reufarlcs this Page to ProVide,Box may mire t�'onal yell construction ho
drilled:
9.Told well depth below hind SUBbIITpAI,]NSTRiJC1TONS �Pm if nexuary.
For aaddpdcwAI140aUdeprlupr er (�,
( '1Q�o0�7(a)Itro� N Submit this GW 1 within 30 days;of weD completion
10.Statk water Level bdow top of eat 24a• For per the followhrg;
d`110f17tfMerui�r. +-! Original form to Division of Water Rasotaotn
11.Borehole diameter; !Ji N �Unk 1617 MSC•R,eleiA NC 27699-1617 (DoVRX
•(m) 24b.1z L*teeY�n Weller Copy to DwR,tJn 12.well eoastr Cdon method. Oka _ rn,1636 MSty Raleigh,NC 27699.1636 d ��(TUC)
(La.a�r:lofty,abb,davapm6,efo) !—
24G For R'seerSu and O EFPPLY R'ELL3 ONLY. =Ja3' "EMe��aFY to fie
M For water Weller rode over 100 00 GPD•Method of test; permit Arogram 1 :�Y toDWliy CCp(,'UA
ype;
Amount. w
Pam Gw-i
Nartb Caollaa Depart ofBnvi<o ( ,.miw.of wader•Reseraop