GW1-2021-02810_Well Construction - GW1_20210923

WELL CON,STRUMON REM v (Gw-I) For h t oral Use Only: �.
L Well Contractor Information: "
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well Cotmaaor Name FROM TO DESC RUOMN
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NC Well CarAraGor CatifieationNamber QM.OUTER CA.MG mblti card wim OR L1PLBtt
T FROM TO DIOUTM TIMY)rS8 M . {•ur
Z 16. CASQIGOR TUBDNG ••. `,.•. , ;=;::�>'..N> .:.
2.Wen Construction Permfu#-OS tX1 O 1111 l }� 49 1 tAM To atst►�tzat Tao�� msz�rs%
Lsr oII app Nmb/e rrAoaranacffatt prrmfts(ic WC Co+any-Start va a,=-,err) fL R
3.Wen Uae(cheek wen ages R R. ;a
Water Supply WeD: '::+7lai�Ql�:.. - +::Jr�>-•,✓?>>: �3'' - � ni'f.:� -
❑ FROM TO �DIAMSFF3 S=S= T> MSTIItiAL
MuoicipaUPublic R g in.
Oc ai(H Cooim6 supply) &AkesidentW Water Supply(fie) R R in
Obdustw1commercial
Oltesidentat Water Supply(shared) ..1a.GROUT .,..
-0 Son OWeUs>100 000 GPD FROM TO MATSUAL ENWLAMf[MB NOD&AMOUNr
Non-Water Supply Well: R IS R AJ&L
OMcnmarmg ❑Recovery R R
Injection Wen:
OAgai*rReobazp ❑GmundwatuRemediation R .
OAgtafet Storage and may ❑SaImffy Barrier D.SANID/QiAi L PACK Of >:c:�i,=
MAMMALrmMAMMAL ,~IIIQFACdMII�rrDtiT189D:•-••
OAquifarTest OS D FROM.ILTO R
OEgnimenmt Technology ❑Subsidence Control R R
❑Geathermal(Closed Loop) ❑Tracer, '2a DRn.1�vG LOG
OGeotbntmal . ling Return ❑Other(eWlam uadcr#2l Remadm) FROM TOasscs�tiox
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4.Date wen(:)Completed: cl-ZO-Z( Well Mg R tt
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5a.Well Lotation: a IL
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FsavyR)NmrName FacrlrtyIN(rE•apphcable) R
P>;ysiealAddres;C4y,andZip R R 1ii�OCl:a"�NR sp
'' % Parcel Wandfiud=Na(PIN)
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees:
(rfwa field,ace lad m is-ff ieat) ' 22.Certification:
NQ , ,, SC . W
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6.Ls(are)the weit(s): OKrmaneat -or ❑Temporary 10) s d We11Coejra= Date
7.Is this a BYevongAs1�t IhambyoenifythattheWes($)Was(Neva)ootavr Mdfaeaotdm�oewzd
repair to an eristffig well- ,CWis or QNo 15ANCAC 02C.0I00 or ISAIYCAC 02C.0200 Wed Cp nvz= n$rara*dr m,3rLara copy
Ifthtel:a rquir.fig art brown Hell amanacffat mforamtton and egdat2 the rmaae ofthe °f tlds nxadhaa brtapvvided to the Nn o
mpatr under#21 twm*seeffon or on the b=kgf thlsfWm 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the bards of this'page to provide additional wen construction info
ooastnwtion,only 1 GW 1 is needed Indic be.TOTAL NUMBER of walls (a d'See aver'in Remarks Boxj You may also attach additional pages ifneceas ay.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_ 3 `f 0 ' ( ) Submit this GW-1 within 3o as of well completion Formu�ere&kstaUdeprhr#&ff�(�+p6-3(�200'Od2@100') days mP per the fellowingt;
10.Static water level below top of cLibW R 24a. For An Wells: Original form to Division of Weber Resources (DWR�
If>w orkvd is4bove a=ftew +i/�/ ( ) fnfotmationProcessing Unit,1617 MSC.RaieiRb NC 27699-1617
11.Borehole diameter: l 6 gym) 24b.For Injection Wtft Copy to DWR.Underground lnjxtioa Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636.
12.Well construction method:, I\D 3 A re
Cie.zaVr,mtay,-bk&act pask eta) 24c.For Water Sn ea and O -Lori Geothermal Betura Wend:Copy tothe
�y envuvzune n1a healthI eat of the camty county msww
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells rode' over 1 GPD:Copy to.DWR,CC,PCUA
13a.Yield�� 5 I+dethod of ftft 1� ftru t Program,i 11 C 11
13h.Disinfection type: ilvL Amount: n �✓
Fo=GW-1 North Carolina Dcpatlm=ofFavuv=morai Quality-Division of Water Resaaces Raviwd 6-6-2018