GW1-2021-01707_Well Construction - GW1_20210209

VULL CONSMUCTION REM� (GW-1) For r i Use
L Well Contractor Information: "
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•action Permit#: FROM ro DIAIAZM *s•T�*•*.
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FROM TO I•I DIAMEM • SLAMSIZE I IffitKKESS I MATERIAL
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oGeothemaal(Heado&r4oling Shy) * Waw Supply(single)
o1z l/Con mercial OResidentW Water Supply(sbwed) 18.'ROUT
f3krigation , OWells>100,000GPD FROM I TO MAT:" ZNMACEMMMMOD&AMovxr
Nor-water supply Well: 0 fL 3 R AA i
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❑Geolhemal(Seafio JCoolmg Rd m) o0dw( under#21 Remaads) FROM To Drsarn riox(�r a�l/i.etc eic t
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4.Date Well(s)Completed: well LD# $ ti
Sa.Well Loeafro IL
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5b.Latitude and longitude in degrees/minutedsewnds or deal degrees:
of"a field,one ladlong is ) ' 22.Certification:
50 W
/ 1 i � -5 -2
6.Is(Are)the wen(s): Loermanent or OTemporary Sig�oaauc o e11Ca Dace
j l� Bysigmig tfasfor�l �tlottlx�rrll(s)was(were)ownaaeettd fnaa�dmnoewa
7.Is this a repair to an eastiiig wen:- 'awe. or o 15ANC4C 02C:0100 or 15ANC4C 02C.0200 Weff Coavwrbn Stmft s and Saar a cap
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—U-Site diagram or 2"donal wen details:
9.For GeoprobrMPT or Clnaed-Laop Geothermal Wells " You may use the back ldf this page to provide additional sell=mtructian info
consauctiou,only 1 GW 1 is needed. Indiwt'a TOTAL NIT1v1
(add'See Over'in Rema6m Box}You may aLco attach additikval pages jf y
��• '''] 'C� V � 2�SIIBMiTFAL Il�LST'RUCTIOxS .
Fos otal well dspth below land surface: ( D� � !` (ft) 'T aadffpk ioel/s Ilse all deprhsf (ermnple-3(a)Z00'and 2(�100� -, �r c GW-1 wit5in 30 days of weIl rnmpletios per the followirg:
4••, l, �`°.'�4''� �'�rl:C2�3a. For An Wells: Original£o� to Division of Water Resources (DWR;
10.Static watxr keel below top of casing: �� E�a��i�'•(tt} � �LI - 1617 MSC,Rol ' NC 27699-1617
Ifva—kvd is above
I.J.Borehole diameter. 24b.For Injection WeIIs:COPY to DWR,Underground lajection Control(IUC
Ptogram,1636 MSC,Meigh,NC 27699-1636
12.WeReonsftection method: R O'�a hq .: •`1'
(ie.� caw���) 24c.For Water SnDphi and Open-Loon Geothermal Retara Weft COPY to th
cormry environmeinai hiea=aepartnent of the caniy worse mstaired
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells1`redo' over 1 l3PD:Copy to.DWR,CCPCUJ-
13a.Yield(gp* Method of test: vli-- Permit Progr�,1611 MSC, NC 2769 9-1 6 1 1
13b.D➢sinfection type: Amount:
Fam GW-I No*Carolina Depar mmt ofEavfrommmW Quality-Divi of W'doer Resaases Revised 6-6-201