GW1-2022-09555_Well Construction - GW1_20221021

ELIt eON3t'RUGTION REM fGW D For Iateanal Use Quip: r '_
L Well Contractor Information: /�
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NC wen Gootiaetor Capon Number R R }
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water supply
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OAgaitaRecbetge MmundwaterRemedistion $
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0Bq mimwW Technology' OSuhsideaoe Control $ ft
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OGeothesmal Rctum) OOthm(e*lainundm#21 Ramada; FnOM !f: TO
4.Date we9(a)Com*ted:,0 /•,o wen ID1F tt tz
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Ste.Latitude and longitude in devusIminutn umads or decimal degrees:
(¢wen&K am ladloog n ) 22.Certifica on:
a Ia(are)the wen(s): OPermanent a r. OTemp nary S of Z L
7.Is title a repair toin cdxftg web@• ' 'a ° 'rO17•I bY�aJYrharrbe-4s)va+(N m)mmoumdataraw�ctmioe dd
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You mVShe8.For Geop�obe/DPT or Qoscd-Loop Geothermal wells _ �m or additional wen details:he bark of this
m*uction info
oorntuctiao,eoly 1 OW-1 is•nm ded. Jndic'Jte TOTAL NUMBER of wens a ( 'See Ovef in Raft B� °abm&ad al wd!o
dulled: l may also attach additioseei pages ifntaasa<y,
24.SOBMITTAL)NSiRUCTLONS
9.Total wen depth below Ind erudite: �0 I '
Forsadtlpfs vatlr btu ail dSPdv/fdf�bent( .3@200,�2_M 00� Submit this GW 1 wldhin 30 days of weII Completion per flee followL�;
10.Static water level below top of casing: ( ) 241. For An Went: Original form tp Division of Watt Resou:oes (DQdR),
$aonvteNdtrafograarti,$'roe-+- ''// tf lnfonnadMR==iogUnit 161`MSC.RaleigkNC27699-1617
1I.13orehok di:meter. 7� gym,) 206 Foi Infection Wen=Copy to DWR,Undagowd Injection CO3W(I q
hWam,1636 MSS Raleigh,NC 27699-1636
11 Welk construction method: ek l r J
(Le.auger,soeoy,Cddk daeerposk eta.) 24c For Water Sa and O Loo Geo h SPY to the
:. 0oudy envnnumemat neatth epattmeot COMY where metalled
FOR WATER SUPPLY R'ELLS ONLY:
14d,For Water Wens oa.
' over 1 GPD:Copy to.bWB,CCPCUA
]3a.Yield(gpm) Jre#Q, Method of tesC_ t r Permit Pmgam, 11 MS
13b.Disinfection type:—� J ��vAmomtt: �02
Fam GW 1' NW&CJaoSma.^,ennrinw,:,,vr,,,:,.,.,,......,J