GW1-2023-00909_Well Construction - GW1_20230120

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2.11'r11 Conshwctlon Permit a: Gl -1 i FROM to nt.L�/erElt TlnelrNr4s 1L5TCxtAL
rr a a,.yfrrnnfr well n.xerrurrran prrmnr f.r.111C.Cn-r,.At$rate'I'arianr&ere.) fL (L ln.
t,Well Ike(check well use): ft, fr. in
15lfer Snpplr Well! 17.SCREEN
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C1(,rnthrrmnl(Iicming/Cooling Supply) (csidential Water Supply(single) rL fL to
01ndmstriolICommc1`631 rD_Residcntial Water Supply(shared)
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❑Ini neon D1Vtlis=1000000PD T n1ATFRLIG rIr LICFAPFIYI hfErROD6.L1fOLaf
Non-Weter Supply Well: aa fL
oMoniw ng O)(ccovc ft.OAquiferRecharge ❑OroundwalcrRcmediation fL
StorageandRcrovery OSalinit Barrio Cf{ ra ilca6fay ROM TO MATERIAL DMrtACLt1F.YrtlF,7AOD
OAquifcrTcst ❑StormlvnterDrainage fL fL
Or-NT,crimental Technology OSubsidenee Control fL fL
❑Geothermal(Closed Loop) OTroccr 20.DRILLING LOG attach additional sheeb if neeessa
OGcothcmlal(llgtin Coolin Return) OOlhcr(explain under 421 Remarks) FROM To DrSCRIPIIon rMor h.mfn ro trxt In rra.arc
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4.Date Wc11(s)Completed: v2 Well IDN a IL G fL
5a Well Location: U
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Physical Address,City,and ip Ft. ft. V
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"21:REM1IAR[GS r� ntt
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City Parcel Identification No.(PM Used hardened steel drive shoe. e
5b.I a6tude and longitude in degrees/m)nuteslseconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) n 2L Cerlificaa
55_Ag7to3 N —1a.o��D000 ,Y 20-7-Z
6.ls(nre)thewell(s): OPermanent or OTemporary SlgrmturanIC=d11.nCn..,o, Date
Ilyslgning thlr farm,l herrhyeerify that the i ell(s)um(men)mmirwed in accordm ce with
7.Is this a repair to an existing well: DYes or ONo /JA NCAC 02C.0100 or 13A NCAC 02C.0200 Well Construction Smmianlr ad ikar a ropy
lfthis is a repair,fill out known sell construction information and explain me nature of the of ill's record has been provWd to the uril oxrrer
repair under 521 mmarkr section or on the back of this farm.
23.Site diagram or additional well details:
g.For Geoprobr/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional µill construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necess=
drilled:r //,, 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ge (fL) Submit this G\Y-1 within 30 des
Aormultiplewellslistalldepdu jdifferenr(trample-J@200'ond2@lff) ys Orwell completion per the following:
24a. For All Wells: Original form to Division of Water Resources(D%VR),
/f uoter f v water level below top of casiag: G (fk) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
rr level is abate casing,rue"+"
11.Borehole diameter: 6 (in.) 24b.For lniection Wells:Copy to DWIJ Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
]2.Well construction method: Rotary 24c.For WLtrSu 1 and O eo-Loo Geothermal Return Wells:Copy to the
(i.e.auger,roomy,cable,direct push,etc.) county environments hplth department lot the county µ ere u=
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droducina aver 100,000 GPD:Copy to DWR,CCPCUA
I BLOW
Permit Irrogrnm,1611 MSC,Raleigh,NC 27699-161 l
I 13a.Yield(gpm) Method of test:
t
13b.Dislofeetion type: HTH Amount: 1 lb.
Fenn(iw-I North Carolina Department orEraira n unml Quality-Division of Watcr Resources Rev4cJ 6.6•'eis