GW1-2022-01763_Well Construction - GW1_20220215

wELi,eONSTltUerrON xEcoc (GW 1) For Internal Use Oaxy: I
1.Well Contractor Infrmation: -
�. S . tro 1`f ►"i f oncceVED .ice.WATMZC M....
wen cama22to xz= FROM TO I DILSCREFUDN
J 3 FEB. 1 00R JR
ft R
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ft. R m
Campmyxemo - i16�INIIVBR'CASINGORTUHalC •'t6miieir ,,'.�,.
2.Well Construction Permit bt: �. o� -7 FROM To DisatnXIL 1 72MCKN S �*e•,�••*
Iduall app?foable oa11 eaaaretlea parmfss( e-WC Cowry,Saud,Yarioreag Cie-) fL 5 3 R 5 Ile m I � i c 7'T'L�•
3.Well Use(checkwen use):
Water Supply Welb ?.f17.s T.•" :Msr.If�x`d,yx.:?.� ^�i: :•, .i_ n.f,
PROM To
SMSEM • TB MATMUL
❑Agricuhrrsal ❑Municipa]/Public R. 1L in.
meotlxanal(Heapap/Cooung Supply) deafial Water Supply(Sfi381e) ft g te,
01ndushial/Commercial ❑Resideabal Wa w Supply(shared)
- ,18.'.GROiTi'•t•� ••••:::::v•;;:- .,,. ••-. •:<�;>''`=::t;;;.::::'`.-r,.:
.-Claigation ❑Wells>100 000 GPD FROM TD I MATER AL &1FrACIEN3YratSUEdD&Alaomrr
Noce-Water Supplyweil: .R R ear
AA
nM�onitiarin8 ❑Recovery fL ft: (7—
❑Aqu Rec�rgt ❑GroundwaterRemediation $ ft,
A� towage F SAIdD!(;d2�1V&LPACS d -' '- :`•�Y3rxti. .: 'mot emu: �'- .: .
❑ S and Recovery IISalinity Barrier FROM TO MAIEEterAL n►mrwe�mrr Ms�aD
CAquiferTesr ❑Sto�waterDrainage R fL
❑FxpamreasalT o8Y ❑SuhsidenceControl ft. ft
cGeotitetmal(Closed Loop) ❑Tracer =ZO:DBII.LtNGIAiC s>f:efiadditia�ita> 'if" - ""•'
❑GeotIumal(HeaftogCoolmBRca=) 00dw(eagflamunda#21 Remarks) FROM TO DZSCRV Mllr(cpbr, nara shL ae.
R R
4.Date Wells)Completed: — 2z- Well M# ft; ft
tZ
Sa.Well Location: - fir .
1 e h a o CA
Fia7ity/owaa<xeme Fac&tyM#(rfapplieable) fL , fL
Mrhel i Ra ., � welsh _ on / ) R f;<
P!{Ysieal Address:City:sadZrp !< ft.
S $S Zl''RMAIM.
COY Frrcel rde oallo.(m)
5b.Latitude and longitude in degreeshnimutes/seconds or decimal degrees:
(F-ell field,eme lad7
2ng is saa5a=) S / ' 22.Certtfr oa:
APO
w -
6. are the
]s( ) well(s): 2, ent:
-or ❑Temporary f Sigoamre ofC-'fie&Ne" Dft
r r
7.]s this a re 1�s+8�s�*l�ra lhaebyarratfyrhmtherrrll(sJ r►ar(+.era)cn,nar�edD,aetizvdaroe,.trl,
pairtoaneastingweli:- ,f7Yes or l�i�Io ISANCACO2C:0100or15A MAC 02C.02MffieffCgv=&&cwnS7vdar3rad8aaa qM
IfdCr is a rgxxtth ari brava well evvnasnCar bybrmaton and she icoaoz ofthe ofrMs mnrdlaa be. p,-Yded go rTu veil o�mo
'rrpa&miderl21,vrmissauon*ran rhebaei:efth&fam -.
23.Site din-rzm ur add dor-1 well:tit l'a:
S.For Geopcobe/DPT or Closed Loop Geothermal Wells baying the same You may Use the;back of this page to pro4ide additional wall construction.info
Construction,C*1 GW 1 is-needed.Iadfcha.TOTAL NUMBER of-wells (add'See Over'in it Boxj You may also attach additional pages if may.
drilled 24.SUBMITTAL INS'IBUCTIONS
t
9.Total well depth below land surface: 2 _U (K) .
For eadBpJi,.dlsifst aII deprhs fo4gv„rr(ea�rpte-3 a(�200•orad 2(a)100� Submit this GW-1 within 30 days of well completion per the following
10.Static water level below bop of easing: k+ (R) 24L For All Wells: Original form to Division of Water Resources (DWRI
Jf 0n&0u Processing Unit 1617 MSC.Raleigh,NC 27699-1617
11.Borehole diameter: •ro) 24b.For Injection WeH=Copy;to DWR.Uadagrotmd hrjecdon Co nmi(IUC)
/� Pmgiam,1636 MSC,Raleigh,NC 27699-1636
12.Wall construction method: 3 b"�3 Y.,, -- •/ k•"y' 24c,For Water Suppk and Opeln-Loon Geothermal Return Weft COPY to the
CLG auk-rotary.COW paste,eon) county eavaonm�ema
epattmen.t ofthe comfy Where,iasea
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produft over 100 000 Copy W.DWR,CCPCUA
Permit Progam,l 11 MSC,Raltii C 9 11
13a.Yield(gp� �0 —Method of test: Y��
13h.Disirfeetion type Amount:
Form GW i' Nordt Carolina Department ofEnvao==nl Quality-Divi u of Waax Resources Reviled 6-6.2018