GW1-2021-00285_Well Construction - GW1_20211213

WELL CONSTRUCTION RECa (GW-_l For lntl>rnal Use Only.
1.Well ConII-actor�Information. "
L S • I\e�'1 e_Gj G1/�) 14.WATER ZD1,0Z
Wen Co=nctacName - FROMTo I)£SC1;:IPri0x
' R R
00
R &
NC Wen Cow Can Number
1S OUTER CASING frai cd iiitts OR LINXR af .,T FROM TO DlAhnM:EL THR'CIISy MA2LRIAL
co=p=y Name _ ft ft m.
�l ;16.II'II�IER GSINGOR TTIBSxG�ot}icaui ,••. ,. ••-.�--:,',
2.Well Comte action Per Dlenn �
ro
.� _mI esAnMIAL
Ilsr all app&ez61t..ell earazrrctfon permKr(ie LZIG Cosmry State,V__m e,ac) R ft 5?��/ m- !{ i c.t YL
3.Well Use(check well use): R. — ;a
Water Supply WeU! IZ'SCFtgSN, Y- - ;7k
FROM .,... -> ':;;: �4_<;::ter:: i`; :-.�rr,r,.r.
TO DIAMETER :..STATSI7z ' '1 i+SA1T�t1AL
❑Acu ❑MunicigaUPublic ft tz to
❑Gart}z,al(Hcating/Coolmg Supply) eutial Water Supply(fie) ft ft. is
❑Industrial/Commercial Residential Wales Supply(shared)
.18.'GROUT
-M on ❑Melts>100 000 GPD FROM TO MATKRIAL I EKPIAc33CDrr MXM0D&AMouxr
Non-Water Sup p1Y Well Q R Z R lVea>r'
❑Mon6oring ❑Recovery R ft — {
Injection Welh r Z:, 42 LL224-i2
ft. R
❑�p�b'C ❑Grotmdwa>zrRcmrdisIIon ,
19.SAND/GMV.EL PACg❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM TO MA'LEIiIAL 1�FACII�@fI'MIeIH6D
❑Aquifer Test ❑Stormwatcr Drainage s. ft.
❑Experimental Technology ❑Subsidence Control ft ft —
❑'G00d=mal(Closed Loop) ❑Tracer =20.DRILLING LOG sttxli a8ditirtaal iSeeti'if
❑Geothermal(HestmgJCoolit, Return ❑Other(«plain under#21 Remarks) 18AM To D>xcs nox ,.a�t.et
ft R
4.Bate Weli4)Completed: f Z— �Z/ Well D?# R R —
I(, QCI d, x V_
53.Well Location: R ft L
ii hG, S C o - ft ft
Famay/Owme Nerve Famay IN(if apph-ble) ft ft
r
�Choo ft ft
Ptysic4­Ad&-s. nc zip 21.REMARHs. ft , - , M- +
—� —
Parcel IdenGScadon No.(PIN) _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifcren&14 tax}at/loag a sue) —
22.Certification:
�NlJ ' SH WL -
.
6.Is(are)the wa(s): ermanenY or ❑Temporary / .3 74' Sig�are Well — Dam
Bys+fflwi9db�Tforn;1hereby certify charr/e wea(s)vas(were)conrvu=dbe a=W%i for wrth
7.Is this a repair to an eristing well:' I OYr s or nN. ISA NCAC 02C.0100 or f 15A NGSC 02C.0200 3Fef1 Comar-ion Soaadmdt m7d tint a copy
!f dds rs a rspatr, u o.c Two+.n+ u won ftvrvfmaa'an arri e;97&o the naaox of the of this?co as?cord h been provided to the+eel!ownv
repatr n'nder t2l sntor,or en the back of gurform
23.Site diagram or additional w4dt details:
8.For Geoprok/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this pale tp provide additional well construction jnfo
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Oven'in Remarks Box).You may also attach additional pages if nece=y.
drlllcd:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below Isnd surface: Z
For rmdtfpls.eells aDdepthr rfz.��(er�pk_3@200'�2@1M ( ) Submit this GW-1 within 30 days of well completion per the followhig:
10.Static water Level blow top of csssing V Q (fc 24a. For All Wells: Original farm to Division of Water Resources (DWR)
If,�er lend rs abMW�Zae'+l' ) lnfarmation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. v {m.) 24b.For Injection WeMs:Copy to;DWR,Undmpvind Injection Coamd qUq
Program,1636 MSC,Raleigh,NC 27699-1636
IZ Weh eonstm action method: 24c,For Water Supply and OperrLoo Geothermal Rttmn WelFx Copy to the
(Le-�rotary,cable,direct pml>,etc.)
coumty envirmm�hea�epaztineat of the eotmty wham i e3
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produchig osier 100,OW GPD;Cqy to,DWR,CCPCUA
13a.Yield(Epm) Method of test
Permit Program,1611 MSC,Ralei;A TIC 99-1 11
O
13b.Disinfection type: Amount 16
Form GW-1 North Cato ma Departmem of F.nvuoumeatal Quality•Diviaon of WaL-r Resotuces Revised 6-6-2018