GW1-2021-00444_Well Construction - GW1_20211206

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WELL CONSTRUCTION RE!Q k_ (GW-11 For Internal Use OW.
1.Well Contractor Inf
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��rmation: -
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L.a r�A.e O 14.WATMZIOM•...
WeII NO= FROM TO I D�IION
1`-1 ►+ oo ft 20 ft.
R R
NC Well Cormacoor Catifieatioa Number 15 Oi7TEB CAW r 6aaembld eased iieDa l3R LlNBR ,,.%?•., .
p E FROM TO DrADEMR Tta fiS4 MAURidL
R R is
x� 5 lP2 iI&Rem ORT M(;4ib
2.wett Canstractlon Permit tt: •2 FaOD11 TO arenaTm Tmmrms F�sss�rsi
Ltn all a�pNoable reAmraovulan permtrs t?a tAC Cormty Smsa YarianoR aaJ ft R S7 -t'h 1e tv w
3.Well Use(cheek well use): R R ;a
Water Supply Welt.
FROM TO :Y DI AMM :"SIA?sm ITffiCHMM MATZRML
OAgnculturd OMunicipaimublic R
cGeothem:al(Re*tJJcooling Shy) Water Supply(single) R R sa
❑IndustriaUCommenciei OResidmtial Water Supply(strafed)
vIcrigedon ❑Wells>100000GPD FROM To �MATZtL►L CEW0M v 0Daaeso
NOR-water supply wew ft. Z 3 tL
OM ORecovery R R
injection ell:
OAquitaRechffige OGmundwaterRemediatim IL R ,
iI9.SAND/GatnixPACB •,,. :.r.tsZ;s= ._3is ?"y'��r�;..•::?....:;.
OAquifet StoraFe and Recovery OSalh*Barrier FROM I TO MAURML IbUgACIII@rrDAlTffAD
OAquifeerTest ❑StormwatcrDrainage R tz
13STe imental Technology ❑Subsidence Control R i!
Ofleothumal(Closed Loop) OTMoer =20:•DBILLlNGLOG(sitieeh=dditinnil'
OGeomezmal _ !q!q Coo' Retum) 00ther(eglain under#21 Remadm) FROM R TO D now ,.tenet :de
R
4.Date Well(s)Completed:J(-Z(► ?' Well ID# R R
1:,
5a.Well Location: ' R
UJ C � - R R
FaMTdy/(:?Wm ama Faer7ityM6(if appEc``abll'e) R R
Plr<vsiralAd&-%ONend2"ip R R
UIGr Cl; ZbREMAR&5 \
Cofmty �T Pawl we don No."o
5b.Latitude and longitude in degrees/minntestseconds or decimal degrees: VM WIT)
(ifvmU field,we UvUq a snfeiem) 22.Certification: UNIT
3(d I b' I�� ' N a3�7" 1 L ' w
6 Is(are)the wen L�(s): ermanent -or OTemporary 3 1i3Q 1 Sig e o Cetnfied Well Date
Bysigtdrr *sform,lhembyeenl Marrisevell(s)was(were)aoraaa=dasaoamdmaoewtrd
7.Ia this a rtpai:to in existhrg wak- •MFes or a o 15A ACAC 02C-0100 co,15A N AC 02C.0200 FeU Cvm*xdm Swdmdr and drvt a copy
Yards to a tagaalr fill ad blown well emaauetloet b06rMewan and cplobr the namm ofthe of rhts reamd has bmrpwvided m the veQ owns
'tepx&wider#21 rmrarbswron or on the hwkethlsfom 23.Site diagram or 2dd1doffii well details:
S.For GeoprobvDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction,info
oonsftuctior,Only 1 OW-1 is needed. ladiedte TOTAL NUMBER of wells (add`See Over'in Remarks Box}You may also attacb additional pates if nectsmy.
LL 24.SUBMITTAL X%'rRUCTIONS
9.Total well depth below land surface: l L 0 (ft)
For muldpk vent list all dgrla(j�ro t(—Npk-3@200'ard2@100� N Submit this GW-i within 30 days of well completion per the fallowing:
10.Static water levd below top of easing: (o (R) 24L For All Wells: Original form to Divisiaa of Water Rwornees (DWR�
F lepattt a3a.+s o fate +• hdinmation Processing Unit 1617,,MSC,Raleigh.NC 276W1617
11.Borehole diameter. 1 b n.) 24b.For Iaieclion Webs:Copy to DWR,Un&Voimd Injection Ca and(TUC)
Prgpmn,1636 MSC,Raleigb,NC 27699-1636
12.Well construction method: R t- V. "^
(ie�zatuy,oabk,fiedpaph,etc.) 24e,For Water en and department Geothermal Reim n We eel Copy m the
. county mvaonm e�th �`tile county ms�fea
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produft over LW GPD:Copy toDDWI,CCPCtIA
Petmft ho
13a,Yield(gpm) Method of test: 1 11 C, ei 11
i
13b.Disinfeedon type: Amount: 1
FOma GW 1 North Carolina Deparmem ofEnvno==tal Quality-Division of Wattr Resoraoes Ravised 6.6.2018