GW1-2022-01909_Well Construction - GW1_20220128

WELL CONSMUMON RECOI — r�GW-1_) For In einal Use oii�y: _
L well Contactor Information:
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well CoatmcaorName RMNE To DESCRE ION
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FROM I To DIADgrE6 IEMCKKM MA72RIAL
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3.Well Use(check well use): _ R R is
Water Supply WeIL• srl7.sCRBS1�.ti. :h�i?r�a:'.�ix t vr�• ��., . = `X 1� Ja;
PBOM TO ia
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OGeothe:mal CH-Ong/Cooling Shy) OR=deatial Water Supply(single) R fG fin.
❑Iadusttiai/Cammat:iai OResidential Water Supply(shaved)
9 as Ia'XMOpi t. s -:;•:. "{:>'. _ F'e.. :;°'.::
OWells>100 000 GPD FROM I To .XMF AC ZMXNT?laIBOD&"oUxr
Noes-WAtersapplywell: tt f-
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Injection We➢: R R "-s Olt
fi: R
O OCuoimdwatirRemediation` .
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TO MA7EUAL zM3%AC XNoM Cl89D
OAqufferTest •OSW=weterDramage S R
EmperfinentilTechnology ❑St6sidenceControl R R
ClGeothemad(Closed Loop) ❑Tracer =•2Q•DRUJMG•L4DG atlitliidditioail 'R-"• p•-
❑Geothermal(8eetiop Cooliaglkztmn) OOther( under#21 Rem) FROM R To Dzsc�ITON sole ,.afi.et -ape:'
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4.Date Wells)Completed: 1-1 S-22 Well DJ# R R
Sa.We4 Location:
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Faa7ity/OwntrName R R
Fa�ay ID�C�� )
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P*=WAddrm ,andrsp a V — R R
County PacedIdeotificadonNo.(PIId)
5h Latitude and longitude in degreestminntesiseconds or decal degrees:
(if well Sold,nee heleag is saf C921) ' 22.Certification:
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6.Is(are)the well(s): II�ermanent• 'or OTemporary ! 2 3p' Sigaatms `4Ven - Dana
> Br•�S�s�*�1�'1'�95'r)n,rthe,rrlr(:)vm(suaJ eara,�,o�edbtaaamd�ae,.irh
7-Is this a repair to an easfheg well:,' I 'es or 15No 15ANCRC 02C.0100 or15ANC AC 02C.0200 1VeQCvavn=bmS3a don&-,ddxira copy
if As Ix�s: c^Sr15-- ae4yfVe efscis 46-W-iTomrr-
'repofrmvderaj Paz=*saffon Qrdn rhebaeRafrlsisforef
23.Site diagram or additional well details:
8.For GeoptvkMPT or Closed-Loop Geothermal Wells having the same You may use the bade of this page to provide additional well construction f&
oomtruction,aaly 1 GW 1 is-needed.lndf oift TOTAL NUMBER ofwells (add'See Ovee m Remmim Box}You may also attach additional pages if necessary.
drilled:_ 24.SUBMITTAL INSMUCTIONS
9.Totalwell depth below land surface: Submit this GW 1 within 30 FornaJtlpk aeQr dgrla jf4b-a(—Vk-3@200'-ad 2®.100) (�) days of well completion per the following:
10.Static water level below top of easing: (� 24a. For All Wells: Qrigioal form to Division of Wtt6Q Resources (DWIt),
If,«aterlead Lt ab0M�fM•+ ) bfonn&Qn P=ess*Unk l617 MSC,Raleigh,NC 27699-1617
1L Borehole diameter. �� (m) 24h For
Iniection Wellx Copy;to DWR,LTndetgound Injection Control(NC)
^ Program,1636 MSC,Raleigh,NC 27699-1636
I2.Well contraction method: D 3 n. /4 'r .
Cm--nvM roeay,-bk,&vap%eve.) 24a For Water SuoDlvsad Oben-Loon GeatherDni Rdara WeIFs Copy to the
:. county envuonm health epar mint county �3
FOR WATER SUMY WELTS ONLY: 24d.For Water War Producing over 100,M GM.Upy to.DW�CCPCETA
13a.Yield(gp4 10 Method of test r►�' Pffm;ftogrum,1611 MSC,Resler C 9 611
13h.Disinfection type: "I Amount
Foan GW-1' worth Carolina Depaamem ofEwhoomeotai Quality-Division of WaterResoiaces Reviled 6-6-2019