GW1-2021-01710_Well Construction - GW1_20210215

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L Well Contractor Information: -
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NC Well Catifradon/Nmmber- I&OU73M CASING
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i Wen Coastrectioa Permat#: PAWL .20.L1 000?d FROM To i DMDDMM. I TIMCEZON MATERIAL
vsr all appNcobk wUamvratan permus(re-WC Cows.Sate Vmtanee,etc) -(-' R (0 R S 7 bL
3.Well Use(cheek well me): R R
Water Supply Weil:
F$OM TO DIAMSFEB lswrsm 17mCOMS I MATERUL
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QGeotYC11021(13catingCAoft Sup*) Wrier Supply(single)
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Q on '. OWells>100,000 CPD FROM To MATERIAL-
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OMostormg ORecovery R R
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OAquiferRecharge OCroundv ater Remedistion
OAgmfer Storage and Recovery OSalioity Barrier • FROM TO I MATERIAL II1�fa�C�@ii MS189D
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OExperimerbl Tedimology ❑Subsidence Control R R
OGeodmoal(Closed Loop) OTracer '1lLDffiIAriGLOG a!l i sLee if' - _=^
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4.Date Well(s)Completed:- -/d L/ Wa m# R R
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5L Latitude and longidade in degreeshumotes/seconds or decimal degrees:
Ofwcu field,one hVIM is ) 22.Certification
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6 ixare)the wa(s): Er•n�aneut. or OTemporary 1310 Sigr»e afCatifierl�VeIlCa acaa Dare
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7.Is this a repair to an a dsfQ:yell:- �.OYrs or a1Fo 15A NCAC 02C:0100 or 15ANCAC 02C.0200 Pell Cp sVveno t Smndm,&ani d--a r7
!f rhir is a sepaa ore bamwt uvu muo%camt afommm mid cp&abt flee nmtae ofdx of dns record has brat provided m dte,.eII owner
'rq=fr mtder f21 rawb sreffmt or on the baaEoftlas forma i
�,a 23.Me diagram or additional well deism:
&For Geo bdDPT or Closed-too Geothermal Wells Q .1`tom You may use fire back of this page to provide additional well conshuebon info
P� P e (add See,Ovee m Remarim Box}You may also attach additional pages ifnecessary
M only 1 GW 1 is needed indicdte TOTAL)1 wells,
24.SUBMITTAL INSMUCTIONS
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9.Total well depth below lead surface: J 2Q this GW 1 within 30 days of well completion per the feilowiveg:
For rmldpte-e&listaAdrptla'tf&ff- t(—oe-3@200'and2@1W) �,ti 101 •;r�
24a. For All Weiisr Ongmat EDxm to Division of Water Resources (DWX
10.Static water keel below top of -16I7ratonrocessngnt! , gh
IfrvamlevelisaEoveoastnp,;me"+'/ ( ''
1L Borehole diameter. 24b.For Injection Wells:Copy to DWR,U Injection Coe -A(IUC
Program,1636 MSC,Raleigh,NC 27699-1636
11 Well eonstractien method: l`O� a►�u . � � '" 24c.For Water Snaph and! Geothermal Return Wells Copy to th
Cie-saver.twaz3,cable,&redp-k ew) county environmental health'kk the oouody where mstEkued
FOR WATER SUPPLY WELLS ONLY: 24d.For' Wells predaci>i¢over 100.800 GFD:Copy tD.DWR,CCPCU.,
Las.Yield(gp*� Mstitod of tart; rt�•
Pamir Prograrn,1611 MC,;Raleigk NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 Nodh Carolina Department ofBn=nnmW Qaa1G.y-Dm=of Water Resomm Revised 6-&201