GW1-2021-07079_Well Construction - GW1_20210915

WELL CONSTRUCTION REM (GW-1) For ftftrnal Usc only: �.
L Well Contrsetor Information: "
L . S . Re h e A
we1lCo�aetarName FROM TO DISC m"MN
3 j 7>S Newman Brothers Inc. 2-DD R 3Av R
NC wen cam Nmnher 16768 Hwy 268 W 18.OUTER CLM as MAz sm°tuolti wells OR 11N1$tt
Elkin!NC 28621 FROM O DUME te> "
-•r R R in
CompagyName -
t 16.1NNffit CA3Il�IGOB TIIBIIQG •,• .•-,, ,. =ice:'+i. �'l.• :..:;:'•
2.Wen Consfraeeton Peem4t a- WS M T D 1 Z S -t D moss ITO mMA==';r- asAmersc
r&r aff'"a-W—9 eoravvevort pe wa(fie.t11G cewuy S=Ymim m aa) # R 3a R 5�Y hL
3.well Use(cheek well rase): R R m
Water Supply Wen:
FROM TO D7AMErSft sums= ,1 MA1lCRiAL
DAgicubmal DMimicipai/Public S. R m
DGeothe®al(HeatingJCo0ung Supply) -B�esrdea- water Supply(single) R R io
oladusnml/Commercisl OResideutial water supply(shared) la GROD? "
fl Dwells>100,000 GPD FROM TO MATMAL ENMgAt�NPM M0D&AM0U?fr'
Non-water Supply Well: R 3 R Akal-
DMonttosing ORecovery R fL y
Injection well:
R R ,
OAquifer Reclttge OGroundwater Remediation
DAgtufrt Stmage and Recovery DSaliaiiy carrier 15.SA mlG�ayst
FROM TO I MATERIAL 'samtACENWrt�ea
❑Aquifer Test .DStormwaterDmioage R R
[2xi dal Technalogy ❑Subsidence Control R R
OG (Closed loop) ❑Tracer =20•Dan--r nvr_I+OG attach t8ditin®al sb"& fi"" ":
13 13volemal(Haft Cooling Realm) OOther(edam under#21 Remadm) EOM TO
u R R
4.Date Well(s)Completed: `— 3- i Well MA R &
R s� p
a�w" yeen Location: 70 3 U Q ", 4
1J oa: -rryny�, ` a ra., R R
Facaty)Owner Name Fac ity Mg(ifgV sVe) R 0/L '
iiut Add c:LLj.soaTp'-- R '
Comity Potel k1cufficotion No.(P1N) I "- 1 1 7 ^" Slit. Ufll�
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DWR.Seddon
(;Ewell fief one ladlong is sue) 22.Certification:
36 ' IL 'fT N w afa�4__o Zxp, 7—Z
6.Jz(are)the well(s): ls3Peratanent 'or OTemporary �a ' Sim afcettise enCo�aemr
� t
ByslgnvTOMfom Iherebycertifydeerthe veft(s)was(true)eornvu=dbra=w db=ewtrlr
7.Is this a repair to an eidsting wen:' •Dyes or MNo 15ANCAC 02C:0100 or 15ANCAC 02C.0200;Yell Ctersaratw Saatdm-&ms4 dre a copy
lfa4ls B a rtpar fell as bmrre well oovavteerJorr mfarmaAoa and apletrr the mace of rtee of this re=d hat bMPVVidod ro the Ha own".
?cparCo der 921 nwwb sarton or on Om bark ofrhfsform 23.Site diagram or additional wen details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wens having the same You may use the back of this page to provide additional adl construction info
conshuctien,only 1 GW 1 is needed Indic a TOTAL NUMBER of wells (add'Sec Over'in Remarks Bo)4 You may also attach additiotal pages if necessary.
drilled 24.SUBMITTAL INS'1RUCTIONS
9.Total well depth below land surface: , Submit this GW 1 within 30 days of wen completion per the fonowing:
Fosradtlpk hells Herr aH&pda ifdffvext(aaarplc-3@200'm+d 2@100)
24a. For All Wells: Original form to Division of Water Resources (DWU
10.Static water Level below top of cammg: (R) lafotmation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Iftwrerkaells dbove aosbrg:rue
11.Borehole diameter. s {m) 24b.For Infection Welix Copy to DWR,Undagaumd Injection Control(NC)
n Progtam,1636 MSC,Raleigb,NC 27699-1636
12.Welk construction method: t CD4 AM 24c.For Water Snatrls and Open-L000 Geothermal Return Went Copy to the
Cie.tinge;-t a3,caw dined push,am) county environmental health departm=of the county whM ms�Tlal ea
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells rodncin over 120 @00
it gr GP M_Copy to.DWR,CCYCETA
Permog m,1 11 MSC, 3�1 11
Ma..Yield(gpm) Method of test: trr
13b.Disinfection type: Amount:
Farm CrW-1 Nmdr Carobna Department ofEnvuonmental Quality-Division of water Resources Revised 6.6-2018