GW1-2021-07632_Well Construction - GW1_20210903

i
SELL CONSTRUCTION RE GW i ® For Internal Use Oats:
L Well Contractor Information:
®V
L S e G•v 14.WATERZ0I4S....
WeIlCo�acmrN�e M To D>>StliON
.3 5 3 s
NC Well CeutildmrCetti Nuzber ' �@JQ roo,�ao� tz $
tip Cj6 11 OUTLR CASOM fw. weBa OR Timm
Mom R To ,
& m
16.'iNNSR'CASa�iG OR TQ�iG - ..-., :;.;:"'•;�.;...�,=i'.::�.':�
2.wen Construction Permit#: 1AJ5 12. 6 2 > ro risers:v r
ISstatl appl►enble Ifta-mv=ftn pcvft 0--USG a Smt4 Ya ---eft) 5 7 tCt1, tZ
3.well Use(theeh wen axes $ it m.
Water Supply WeIL•
❑,-__.` , ❑ tlVt Ta 11 srtrrs=.I Tmcmum I•flf.'RQ7.7.
[lgicAain${ R R hL
OGeothamal(Heatin&Cmling Supply) Eid=aler Supply(single) g ftOI i/Commercial ❑ WaterSupply(shared) 18'.GitOUT:.: :•:.:. : ;;.: _;�;._ :: • ..
OW >100.WO GPD >zcM To RffUC_nWrPQ=OD&AMOM
Non-Water Supply WdL- 0 R R N �' X,d
i
luj on FOAquffuRecilarge
in nn. ❑ ` v� R
ft
❑Cm�dwaber Remediatim
Storage and Recovery ❑satmny lamer TO17ROM ro ., rs..T. >�wo�rP=MMT� _OS vramrDlainage ii R
x:zW Tecbnology ❑S 'deme C mftd tz R
mal(ClosedLoop) ❑T :'20.'DRDAMGIAGaltscriddifimais6eElrif +:
OGeothermai(,Heatio0coolingRetum) ❑ (explainunder#21Remadm) To DESCRUTM>s at
6 I, � &
4.Date wells)Completed: O - 31, ] Vf+en]I* ti y,
ft
Ss.wen Location: R
A l��er►v �Tr ►a R R ZPik 11
Faep/O,x°�°r/N°ax M#(ifye) R. R
Physieat Address,Citj,and R R
] ZL
ldeacfrcadon No.(PIN)
Sb.Latitude and longitude in degneshninates/ nds or decimal degrees:
(-Ewen Se1d,ene letllong is saffieieot) ' 22.Certification:
3(,• I 7 N Xb t H-7 ±7 * W
9 3 1 2,1
6.h(an)the well(s): QPermaneat 'or OT'emponwy 4 0 S' Date
Byn8ftAftfom lhetebyev*Artdwwaa(:),vas 6mm)cwnvzw*dfa=n1v oewith
7.b tills a repair to an eidsting well:- •RYes �r a, 15ANCAC 02C.0100 or 15ANCAC 01C.0100 We&Cw=hxnat Sw dmrlr mat d-a Dopy
.1fzW is a:q=b mi and ugTebr the moor ofd a of this re=d her been provided to the well awnv.
'?qwb-tinder 021 nwarksectton ormt thebaeRofftforla 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop GeothermI Webs baying the same You may use the back of this page to provide additional well cons4t�infio
construction,a*1 GW_1 is needed. Iadicke,TO AL NUMBER of wells (add'See Over'in Remarks Box}You may also attach addit and pages if necemy.
drMa, 24.SUBMITTAL9. INSTRUCTIONS
FoTmuht veilsotid well&hho apth Ud�hsIId�� ( �. Submit this GW 1 within 30 days of well completion� d4�ifd�»(�hti 3 'atfd 1®100') ys mp Per the following,
10.Static wader level below top of casing: p (R) 24a. For An Wells: Original form to Division of Water Resotaces (DW4
�„ kwalLs a6aer & -j+. Information Processing Unit,1617 MSC,!RaIdgb,NC 27699-1617
1L Borehole diameter. 1p( 1m) 24b.For Infection Wells:Copy to DWR,Undagoimd injection Control(IUC)
n Progzam,1636 MSC,Raleigh,NC 27699-1636
12.Well contraction method: I`A a h /i. t" 24c.For water sna and Open-Loon Geothermal Return WeQx Copy to the
Cu mo;:omy,=bk duvetpush,etc-) . � county tmvannmenrat aeatm department:ofthe county whQe Installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water We& rodn ' over 1 GPD:Copy to.DWR,CCPCUA
13tt.Yield(gpm) Method o test:. A
PermitPmgmm,1011 C, 1 11
13b.DidnAwdon type: f Amount: 2
Foam GW 1 Naatfi,ICu U.DepartuM ofEmnonmenral Quality-Division of Wader Reswaees Revised 6 6-2019