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HomeMy WebLinkAboutGW1-2021-03253_Well Construction - GW1_20210628 WM CQNMUK r ON RE v Gw 1 For�alUse only II� L wen Costraetor Informatiol .I4.WAI=2X)M... FROM TO D>s'S�!!ON wen Coouaetor 3 5 5 56 R. g oo ft. I � NC WeIlCautisctorCatiSradaa i5.0i}TSRCA.�tG " wells ififfs Film To DIAMSll3RMAIERIAL R R i in Cam�eayNmae 31LBe RCA3IIVGORTURIG 2.won cen weedea permft e1 W FIRM TO i Lilt all gWA=blemff aomaacuan Vvft xs C MW.sm Yar+at M eta) +1 R /01, R �y YrY I1Z-- 3.Well Use(check well used R R t I m. SOUWater 3 i1Zi Wat WeM :, •: . .; _ - -K . •° :=-_'' i %: uPpl9 FROM TO. DUMUM •: 3=8=•.I nA& I t]MtmelrFublic R R �. nGWel(g 8 st>! Y) al wa8r Snppiy(sinee) R R 1 tn. [� ❑Residential Water Supply(shared) -.IL GROW fl nWetls>i 00o CsPD > M i'o iasziatrsi �ei[otrxr NOR-Water Supply Weta: R 2 R :' •t�/ nMa�oaitsg _ perry R $ ,mil .s L#ecBon Wem - ft nAgaiferRwharge j nCrotmdvvatmRemediati(ul ;Ig,SAP1D/QiAS�LPA �f" r1�Y; ra' ' nAquffw Storage and OSal i*Banier • HROM TO waa+4er.T- MC�6D nAgaifaTest nStoimwaterDAdmF .R R i oBgmimamd Tecbnology nSnbsidenx Control R I i _ nGeothem�al(Closed Loop) ! nTra= =20t•DRnJMG LOG atti�'l incurs if y=: `•: ': :. aGeodmMill . Rom) nOther( ' umda#21Remadm) IMM ft TO R i i ENItS& etc 4.Date Wells)Completed: Z2-ZIweD IN R R R f! Sa,Wez Lomfion: nl �Sk - R R i rams ID#Cifgv ) R R � Fmli:y/O+eoQN . R ftAA;eCO(0114- Cda ft ' ears Pa:xilkeffea ionNm"0 C 5b.Latitude sad lode 11 ieg'ee ftmamwseconds or decimal degrees: gwen Sell.we bobag is ) , � Z2 Certifinfion: C �O �' �� N �� a � �• a w � L— 22-21 Dow 6 U(sm)the weA{a)rLl aunt' or OTemporary 1 76 s ane I eu+ j aYj3dW trsfom'h—byceraACO2-0200lrmez (wvyavanrreaea8iaoddAJra p 7.5sd&arepdWtoan we&, •D.Yes or .o ISANGICO2C.0100orISANGICOZC.0200iY�Co +S � a�P Jf�ttrfsatgpatJ;f+llard,btonti ov is ta'dawatithemomOfda of tlasremidhxrbmep+eaf�todrs�IIoanv trpmr wader 021 nmmfssawat 4 r on theha&of tw5foras 23.Site diagram or aiiiiidoiad well detarlls: L For GeoprobeWor or Cl Loop Geothermal Weds having the Salve You mgly use the back Of this page to provide additfOnal will OouSM=dnn info cottsezuarao,ably 1 GW 1 is 3n&cka TOTAL NUMBER of we1Ls (add See Ovee is Rerriadcs Boxy Ybu may also attach addWorml pages if neoeffiM dulled 34:SIIBIYDTI''AL]NSIItUCTIONLS 9.Total well depth below surface: Submit this GW-1 wit 30 days of well completion per the fellowieg: For rmd**weAs Est aII depeT+ iff--(-oVLe-3@200'amd 2®100) 24a. For All weal: ongaoal £omz to Division of water Resmaees (DwR; lo.Static water level below1 op,of cnW (R) hfirnmation processing Unit'1617 MSC,Raleigh.NC 27699-1617 Ifmna tevrt fs�aoe aast�psi�+-/�1 iL Borehole diameter. !" jm•) 24b.For iectfon Wellx GOpy to DwP.Uadaglolm l bljeetion Covird(NC' 1 ^ Program,1636 MSC,Raleigh,NC 27699-1636 IL W&eonsfracfien meld 1`07 3 hit /"1�r 24e.For Water SnnT s O I isam Weft Copy to th (ia ao,�misty,-W donut eac.) co�mty eavao®meatal health' the eotmly vdlere mfiftlisd FOR WATER SLIMY ONLY: 24d,For Water WeIIs vioducluglover 100.60Q� Gl'D:Copy tO.DWR,CCPCUe �—„ — - Permit tTUg<'aID,i6111viJly tcatRgta,i��. vaa ]3a.ydd(—I Method of test: 13h Disffifeefioa type: d' Amount: 12 Form GW 1 I� NaetitCaeolim Depatmm ofFsvitonmeatat Qoainy-Division ofws Raviaed6 6 ZOl