GW1-2022-03893_Well Construction - GW1_20220412

WELL eONSRUCTION RECd — se Onty.
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well Contractor Information:
wenCaQtaetprName FEOM TO DLStRIEiiON
4 4 ;Lo o R• qv out
NC Wen eommeaar CaeL=d=Number
MOU71RGiMG Sme[mfilOetsed'+die4s ORrZNM iV' .rx..•-.
✓•V 1•/JiKV.7/►'� FROM TO I D7A UMM TIC 71lAILCW.
Ca®PUWx=e & $ in.CA.SIIVGORTURNG Cott t •�., .'
2-Well Construction Permit 8: (/ S G�i mom M TO DIMIU Tnoe® assmwr.`'
rJsscuappirmbleveueaaaverlonaerr�rs(Pc tllC eoiatsj+.sm�vm m.a ueJ ti Z rL 57 hL
3.well Use(ehee_ic}well ase):
Water Sappl)WlD: 'N7".Wi�OOI\l. �.1� :1J Kf�R 4•iM�Y�.e�f�J�ly�r t•� M
' .: DIAM8IEB SIATSn•E '••.1 1+tA120tiAL
D'Agn PSOM TO
rttlbasl DMunterpaUPutbhc R &
DGeothe:mal(HeOmwcoo]mB Supply) deatial Water Supply(single) g ft I=
u 0hu t ialfiCom ,emir /DRa dential Waterr Supply(sba%ed)
JkakourDWells>100 0W GPD FROM TO rMwT�ur. :;' a�rwco®rrMan3oD:J►Motlerr
Noa-Wager Supply Well: g , t
DManitaQittg DRecovery R R
Injection well: rtiew
8 &
DAgtzftP xhmV ❑Csotmdwamt Ramediatioa .
DAgmfaStoaageaodRecovery DSa1h;kyBanier
TO MATFRrAL ltt►!Z•fACtl1@rrMrzffm
DAquiSes Teat 0Sto=water Drainage ti tt
DFxperim®taI Torhaology ❑Subsidence Control it 8
Dileotbeanal(Closed Loop) DTracer -1Q DBII.LINGIAt' atlichadditno®LlSbeetiif ~`. '' °
DGeo&e:md(ge8UVCeolingRcami DOther FROM To assc�aorr outs �.aa.ei eye
(explain uada#21 Rematits)
4.Date weu(s)Con*eted: y-5-tt. Wang R
Sa.WeD LotaGon: - R
_,� � • JttiK ��.s R
Fs=1ity/Ow=Ns= _ 8 8
ql
Addeeas,(]ty,sadTp %
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;? v ^#vlfir;
Sb.Latitude and longitude is degtees/mmnirs/sewnds or decimal degrsa: •
(if-dl 6.1d,one 1a/loag is sow) •'
CertiScatioa:
3G, N r IS ' 1 i q-,► W 22 .
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6.Is(are)the well(s)�ermanent or DTemporary 1 d S ofCCdSed;WcU� - Dab
B'jf8z+8>*1b-;Iherrby jyr d.dk-wU(s)ww(werv)mmvu=dfa=wdmoe,.M
7•Ls this a repair to as existing well:' •DYis or o ISANCAC 02C.0100 cr IsAjvcAc o2c.0200 irez Cpnvuetimt SrmAV*and gw a copy
Ijlhtttradrp�YFTlw?bmwni►slleavaaroetlarby6rmmrmra ACHavo:ofow ofd*j0= hmbeatppovtdedmdrewrIIonev
rep�aadsitll rarrorlssnaron ororr lhebarkofthfsform 23.Site diagram or additional well detaar
8.For Geopcobe/DPT or Qosed-Loop Geothermal Wells having the same You may use till back of this page to provide additional quell consttuce a ido
oonstnicdM only 1 GW 1 is-needed.itlic'dta TOTAL NUMBER ofweDs (add'See over'id R,m Box).You may also attach additieasl pages if necesmay.
drMed LL 24.SUBMITTAL,Il�I.STRUCTLONS
9.Total well de below Ind surface: ` 3nbmit GW 1 within 30 days of well completion the foDo
depth below
( , y mP Per
10.Static water level below top of easing: 24a. For AD Wells: Original form to Division of Water Rwoureta (DWR).
If, letrd is dboNe omda�pse l"+i/ on Ptucamin$Unit 16171M5C,Raleigh.NC 27699-1617
1L Borehole diameter. ( � tm,) 24h.Foi•Inieedon webs:Copy to DWR,Liadezgouod WwtWa Ca®w MJC)
hapam,1636 MSQ Raleigh,NC;27699-1636 •.
12.Welt eonstrectioa method: �7 d�-i—/ '►t' • 24c•For Water Suvjftand Owed-Loon Geothermal Return Went Copy to the
(ia awe;tan!'.cawdaeerpmL,ft.) county eavmxunhealth depmUnectottbe county whate mimed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells prodaft over IM GPD:Copy XDVU,CCPG'IJA
13a.Yield(gpm) Z 0 1 Method of test: Pemuc Pt093111,1 11 MSC,RWci ,-N-C 1 11
13h.Disinfection type: ? Amount: Z w
Fom<GW-1' NorthCamliaa Depattmrat ofFavimomeatal Quality-Division of Water Resomoes Rwbed 66-2018