GW1-2021-00359_Well Construction - GW1_20210127

YELL CONSTRUCTION RECO. (GW-11 For htemal Use Only: �. t
L Well Contractor Information: "
13 D . A l-��a 1.d Per 14 WATERZA�S _
Well CoatmocscrNmme FROM TO I I DFSCrioN
1 c50 ft Op fi
NC Well Cow Cati fieatinou Number I&OUTEg CASIlYG faa° iveRs OR I.I[tBR'
FROM TA DTeIK8IE8 1 MATERIAL
Nl/�coropmy
_
ItL)INNER CASING OR TUB1PTCr .'.(
2.Well Construction Permit#: FROM To DIADMIM ffiCMUM a MATZMT.
LJst all apph-bk wen cmanstctan penis/u Wr—Cam.Smeo Yoriance ucJ R 31 R S'/?j is k.
3.Well Use(check well use): R R. ;a
Water Supply WeIL• ':17.-SCRB>$i: s. i;:-
FROM TO :DIAMEM S=SM i TffiCRSS I MATERML
Agicuhural OMtmicTdiPublic ft R m
❑Gwthemral(Heatmg/Coolm Supply) ❑Residential Water Supply(single) R R
❑ladusftWCommercial ORtsidental Water Supply(
on , OWells>100,000 GPD FROM I TO MATERIAL EbUTAC8OMAIMMOD&AMOUNr
Non-Water Supply Welt D R 23 R ea f- y.e d
OMoaitaaing ❑Recovery R fL -
Injection Well:
fL ft.
Recharge OGroundwater Remediation .
�_<:__gar , �:....,_.;..
;Ig SANID/QL+\S?BL PACER--• _ z�.,_"ar.:.�.-:.:;:�:.='•c.::
❑Aquifer Storage and Recovery ❑Salinity Barrier • FROM 170 iMAMMIAL I zM21AMMMIirldCIEffAD
❑Aqui£erTest ❑StormwaterDrainage R 1. R
OFxperimeaml Techndogy ❑Subsidence Cowl R R
OGeothezinai(Closed Loop) ❑Tracer 20:-DRI JIKGLOG.ateaefi$dditionalibieWif
❑Geothermal(He ad*COoIIDgReturn) O0d=(esplain under#21Remadm) FROM To Dz noNcolor; asB/raetc etel
R R
4.Date Well(s)Completed: (-21-�'► wen ID# R -
Sa.Well Location: R R
Famky/Ownw Name Fac ty ID9(if applicable) R. ft.
t rus fir,,. A h. lAoR ia Trw R -
Physical Add�;andzip —r R & -
wp ' 2L:itFwreFM., -
Ca®ty M•� Parcrl Idcat6cadonNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweli field,me ladtong is sue) 2L Certification:
/ /-ZZ- Z-
6 are the wells: Pf ermanent or OT Sigoanae ofCercSe"o Date
Bymfflzmg d=form,l herrby cerajyrlsstdhe wells)was(were)cm smectd hiamordome wa
7.Is this a repair to an e3dsdn welL•' •RYes or 0 ISANC4C 02C.0100 or 15ANCAC 02C.0200 A'eII Comi ueaon Srmodmds and dray a co;
If leis is a rapafi fiII Deer lam,vn well corzscuctlone erheryp{e of the of leis recoil has been providaito dre Weil owner
repair order 921 remark section or an the bark
23.Site diagram or additional well details:
S.For Geoproba/DPT or Closed-Loop Geothermal Wells Having the she' • "i You may use the back of this page to provide additional cull construction info
construction,only 1 GW 1 is needed. tndkr,�be•TOTAL NUMBER of veells (add'See Ovee in Remarks Boxl You may also attach additi®al pages if neoesmti
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 y o (fL)
For mrddpk weAs list aff deepda ed�aent(esmnpk-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the fellowiag:
30.Static water level below top of using y' ( ) 24a. For All Wells.1 Original`fog to Division of Water Rwotaees (DWIV
110.St keel fs water
lea .+, lafarmation Processing Unit 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. ' jm) 24b.For Iniection Wells:Copy to DWR,Undergro,md Injection Control(ILTC
Program,1636 MSC,Raleigh,NC 27699-1636
12.Welf construction method: 1 O f 2 h., A r Y 24c.For Water Supply and Open-Loop Geothermal Return Weft Copy t),th
CLG-iM may.cable,Wiper,et--) county environmental health dgmtmeat of the county where
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wel s producing over 100,000 GPD:Copy to.DWR,CCPCU.
Permit Program 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 2 Method of test: r r
13b.Disinfection type: Amount:
i
Form GW-1 North Carolina Departs ofFnvaommental Quality-Division of WIasor Reso uoes Revised 6-&201