GW1-2021-02779_Well Construction - GW1_20210811

1
WELL CONSI RUMON RECQ Imtsaal Use Orly: �.
i
L W40pn1ractor I Ormation:
.14.WATIRT.ONFS....
well Name FROM TO DESCREPrWN
�ft• Sad �
IL IL
NC_ W 15..OUTMCASiriG faa�mnitiessedWO ORTIM
FROM TO D1AM81&8 MAIN s MAIEWL
ZrI
canpu9 ft ft is
Names aG'INNSRCASIIQGORTIIBIrIG tivicemi[
2.wen Comtractio Yarmit s: iBOna ro aisasrne MAarsL
1404ftapp8eablewea a WvNMIDnPvvftA&iAG Co +0 &2$.-v4vfarx4 etc)
3.Well Use(check w ell user ft m
Water SnpplyWed ;17.SC128SN ma's<:.i
FROM iO DIAMEIE$ SIAfsm TMCv= ='MATZU&L
E3Mu- ft ft is
❑GeOthezmal(Heatm Xoolmg Supply) Water Supply(single) ft ft in.
❑Indust<iaVComm OPes dential Water Supply(sbmed)
.l&.QtOITr
fl OWel s>100000GPD FROM TO I NkTRRUL za Yec rr74EXEM&AMOLM
Non-Water supply I I Vem JQft23 fc ew
OMonitorntg aRecovery ft ft:
Injection well-
❑Aquifierltwhap OCxroi mdwaterxemediation $ ft.
❑Aqu i*rSterage=1 Recovery aBarrier -F
FROM TO MA7FRrnL
❑Aquifer Test .13StornwaterDminage ft
OExperimental Techr olow ❑S Control % ft
00w&ermal(Closed Loop) ❑T ,2A;=lIMGLOG(aft&naeMIoa: ih"ffA ..
❑Gcotliermel g ling Return) ❑ (explain under#21 Remarks) FROM TO Dt nox ,.v�.et eec
ft R
4.Date Well(a),Coq ieted: W,0 ID# IL R
Sa.Well Location: -
ft it
Name 00(¢appfiable) 1 $
1 A ) ./�d. & eS5In
r at cats. z $ tto oY:o ft.
canny raemmfaaNa cpnn
Sb.Latitu and to de in degrees/minutes/ nds or decimal degrees:
('fwa Sell,de one W1028 is saf=cg) 22.Certiticadom
wV G �, /L.
6.Is(an)the well(s): ermsaent 'or ❑T nary cytj Q Sigoaaae ofCerdfied'WeHr4U"c or Date
Bs'O1 d*!bmIherebyeatfytlwAe,.eats)w=(wee)cwvvuceed1aaw nd=w.Nh
7.D this a repair to existing we0:- •ayes r o 15ANCAC 02C.0100 or ISANCAC 02C.0200 Weft Car M man Srmdx*and dw a copy
Ijrhls Ha rymafr fift eru MWVaVX9VZCffdff' and esplaht the twaae off a of dus--dhm been pv»,daad to the wa ammo
tepatr rwder all union or on the baehof tlris 23.Site diagram or adfttioaal well details:
8.For Geopmbe/D or Closed-Loop Geothern al Wells having the same You may use the back of this page to piavide additional vmml construction info
commotion,only 1 C W-1 is needed. 'i&cdte TO AL NUMBER of wells. (add'Sm Ovef M Remarks Box}You may also abeh additional pases if necessary.
drilled- 24.SUBMITTAL INSTRUCTIONS
9.Total well depth I dow land surface: (ft-)
ForendBplswellsBst &phs iId&ou lmoNe-300'md 2(a)100') , Submit this GW 1 within 30 days of well completion per the following.
10.Static water lev below top of easing: Q (R) 24a. For All Wells: Origimt form to Division of Water Resources (DWR),
4Iwawkvd is aba.e ire +. /� hiformation Processing Uhj�1617 MSC;Raleigh,NC 27699-1617
1L Borehole thane f—) 24b.For Injection Wells:Copy to DWR,•Undergromd Injection Control(NC)
Piagram,1636 MSC,RaleiA NC 276*1636
12.Welt construeti mtthod: of 24c.For Water Saayls and Ooea-Loon Geothermal Retnta Wells:Copy to the
(i a i°°°� 1►-b.eoc owmiy enviromneniar health dg=tment of the county where Muen
FOR WATER SUPP LY WELLS ONLY: 24d.For Water Wells gggftMgg�GI9 W GP-Copy to.DWR,CCPCUA
132.Yield(gp� 6 Method f tesC
/� P=2ft rtogram,1611 C,
136.Disinfection nut:
Foram GW-1 N Carolina Department ofEaviroamenusi Qua*•Division of Water Rm=es Ravised 6b-2018
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