GW1-2021-06815_Well Construction - GW1_20210110

WELL CONSTRUCTION REC01 (GW-1) For btemal Use Only:', �.-
L well Contractor Information: -
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Wed Cocaetor Name MM To I DESCRHTM
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Lin dff areas f-EEC:C= sm-,vmwwp. 1 R 3 R S ]f is 18K tv s�Pej
3.Well Use(cheek wen nsex & R m 13 4J
Water Sup*Wen:
pMM I TO DIANam smsrti� ...:ffiE��S4 Dt�1�iAL
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0Ge0&anGa1(13eath*r,o0jjng Supply) A Water Supply(single) R
nResiderijal Water Supply(shared) 18.GRODT _
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17 , ❑WelLs>100,0M G?D FEMM ITo MaTERML tlECIRM4b"Oun
No]*-Water Supply Wen: oR R
OMordoring []Recovery R R
Injection weal:
R R !.
O&ffiff r Recharge OGroundwater Remediation _
19 SAND/GR&V LPACS
OAquft Stora&e and Recovery DSalmity Barrier • FROM I To !MAT�rAL a�rrt+srta9D-
Mquifw Test ❑Stormwater Draiffige $
OFapwkwntd Terbaaogy ❑Subside=Conbrd R R
OGeothemral(ClosedLoop) ❑Tracer 7WDRl1JMGWGIRM
attasiiad
OGeWal Xed*C0o1mgReran) DOther(explain under#21 Remarim) To DffiCRa!IION sritreet :etc
it R
4.Date Well(s)Completed: 21 Well LU# IL R Cl e 5 S
5s.Wet!Location R R
F=UyA)wne Name Fa y 1 W.(ifgVH=ble) J R C
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5b.Latitude and lonipiRade m degreesk omotWseconds or decimal degrees:
afwed S014 one kding is saflicieot) 22.Certification:
3(9' -7 "-FS N &(' 4 w ,,,,
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6 Is(are)the welt(s): Permanent or DTenporary 12 to b' s*-ft a ofC-ff-ed'WeIIC-ft-= Dw
' Bysigdngt)es�I berebyoer6fytlnt the neII(s}nos(Derr}cnraoareedSr omondmroeva
I.Is this a repair to an esisfiog wea, •GYes or f PT0 ISANCriC 02C:0100 or 15ANCAC 02C.0200 iveII Cgvabae�ovr Savdmds andChar 0 cop
Iftlns 1s 0,Wa&.fu otdbtowr nrl!avtavrrcooa argon and CTLa t the manor ejriz of tJris rrrnrd lros tom provided to dx ved onto
A petr rodrr 921?mark se coon err m the b=k ofm&fmas 23.Sift diagram or additional well detarlk
8.For GeoprobrMPT or Claeed-Loop Geothermal webs having the same You may use the bark of this page to provide additional well co on info
oo�uttaroa,a*1 GW 1 is nee3ed lndicbc.TOTAL NUMBER of wells. (add`See Over•in Remarim Boxy You may also attach additional pages if nea.4sary
drilled !,, (R) 24.SU MITTAL 1]!UMUCYIONS
9.Total well `�.�O Submit this GW 1 within 30 days of well completion per flu fellowing:
For malnpfe ne1Lt Hsi audWhs -3@0 2Q0'mrd 2®100�
I0.Static wafer level,below top of casing t7 (R) 24a. For All Weir Onginai f. to Division of Water R. (DWR;
Static
a rove e. .+- ca bknnadon Processing Unit 1617 MSC,Raleigh,NC 27699-1617
1L Borehole diameter. /b (n.) 24h.For Injection Wens:Copy to DWI.Underground bjection Contra(IUC
Pragram,1636 MSC,Raleigh,`NC 27699-1636
tz Welk eonsttactien method' ' 3 r 7.4c.For Water&A&and 9ma jen Geothermal Rena Weac Copy to th
cj-Mse;-Wy.caw dradpak ctr-) entry envua®nenW heaft degartneui ofine aouuiy van ins led
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Welts over 1 GM-
Copy toDWR,CCI'C1Je
131.Yield(gpzo) I Method of test: Fermrt Frogram,1611 MS5 RalejOb NC 2769 9-1 6 1 1
13b.Disi fccdon Amount
i
Foffi GW-1 No&Camlma Depart ofEavaa—cmat Qm*-Division of Water Res== Revered 6L-201