GW1-2021-02809_Well Construction - GW1_20210923

WELL CONSTRUCTION REM� (�GW-1) For Internal Ilse Only: �.
L Well Contmetor Information: -
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4.Date Well(a)Complitod: J- wen m# R
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5b.Latitude and loneitade in degas/minutes/seconds or decimal degrees:
CtfweeII Se1d.one bdloag is sue) 22.Certification:
6.15(are)the wel(s): permanent -or CTemporary I � Signaane o eII�Comiacaoz Diu
ByjiVft defrfwn IherrbymrafyA vt the wedl(s)vas(enae)a omvucmdDiaesmefmaoe WA*
7.Is this a repair to an etdatiag welt •Oyes or J*No IsA ACAc o2C Alpo or 15AArAc o2C A2oa wea Cpmrrnena+&-*n t and dart a copy
IftTds 8 a repalr,�l!aa,brorR well aooetDraeNan Dybraraaan and espdaat the rwnae ofthe of thls xao+dhar brae p�+fdrd w die wr!!mnng�
ioider t 21 u+emarts seeCott or an the buret afthfsfonn 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells baying the same You may use the bade of this page to provide additional sell cow info
constnictirn,a aly 1 GW 1 is needed.lndiciw TOTAL NUMBER of wens (add'See ove'in Remarks Boz).You may vbD attach additional pages if ne mery.
drnBed: 24.SUBMITTAL DiRRUCTIONS
9.Total well depth below land surface: 5 Z 1) ( ). Submit this GW-1 within 30,days of wa completion per the following:
For Dnrt*kwallsksiab'depdaff4ftreru(eza no-3Q200'aed2@100')
10.Static wager level below top of eating (�) 24a. For An Wills: Original fors to Division of Water Resomeos (DW4
1f Static
rs water
Le�. op c/ )motion Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1L Borehole diameter. I O jm,) 24b.For Ink:ion Weft Copy to DWR,Un&goumd bjadion Cool M3C)
Program,1636 MSC,Raleigh1 NC 27699-1636.
12.Well construction method: L< D' Q hA /-1 F1' 24c.For Water Sovuh and Oven-Loon Geothermal Aemrs Wells:Copy to the
CLG+qM-any,caW duact per,etr-) county eavM=menW bea= or the county vmee mstauea
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells p"cing over 1 GPD:Copy to.DWR,CCPMA.
13s.Yidd(gpm) Method of test .'Y Permit Progoam,1611 C, 11
13b.D--' I etion type: Amount: W
Form GW 1' Nmtfi Carolina Deparmoent ofEavnonm=tal Qudtty-Divmon of water Resomoes Raviaad 6b-2018