GW1-2021-06002_Well Construction - GW1_20211008

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FELL eONSTRUCTION REDO tGW-11 For Iatemal Use Only.
L Well Co ftctnr Information: -
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Wes CoonaomrName FROM TO D�TMN
100
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NC wen Coa>iseomaCat>S aNrmtber ISM OUTER CA�iG!ia< wel f OBTn=
fd
3 FROM To DIAD� 1ZD 11tATt�W.
Com;+agyName 1 A&n�UMCASMORTQmvG B
z.wen Coas�actloa PerfDft :-- -_t .J 3 LA) FROM TO i DIABILTM mmaes e94=11M.
Etstaawpand&UnaoarraacCaRPm=ffsU UIC .Smm & 5 R !j 7 bL
3.Well Use(cheek wen aser � !i in
Water Supply WeL.
FROM ITO DIAMt1T8R SLCrsm : 1ffi MATIItiAL
DAgicalbnal �DMtmicipai/puhiec R R in.❑C a1(Heapag/Coolmg Su)ply) ,�pJ water Supply(single) & m
Oladustrinl/CammaeialdResidentW wa Wa Supply(sowed)
_ .I8..QtOUf'•
21odgetion OWdls>100 000 GPD FROM 1 To MATsiue.L SAMACENICK1' MMOD&ANOOff
Non-waterSEpplywem. tL tt
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DAgaiferRerhmge OGmundwaterRemediatim
l7Agmiter Sta:age sod Rtxovay II Bauier :i9 SAPID/C,dtAVRL m ¢__. ._ � :�. �.L&n_
Salk* FROM 1110 1P MAMMAL rIRJSA®
DAquiSerTeat DStommaterDtamage .S. &
D Tadmadogy ❑Subsidmm Conhml R a
DOeot)mal(Closed Loop) OTracer ?1a:-DD2LTZ4GLOG aC>tehaddiYm Ii3eetsif ';:
❑Geodmrmt . Realm) DOthsr( utadet#21 Remedcs) FsoM To DBSC6ngwN kwdmmsai/nea AL
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4.Date well(a)Completed: Q` 'Z/ Wdl ID# $ e
S well Location: &
Nvberr G-r� - R s 20
F=UV/OwmName FaediLyMicifgViiabme) tt. ' ti llli
( b? D 1 A U d 2ri►—,ol k1c, g t�fi3rr„ tton
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co-w .z Pmeel la —Na ePnn
Sb.Latitude and longitude in degrees(mmDtes/seconds or decimal degmm
(rfweIl 5dd,a®e below is saSckw) 22.Ceri ficatio
N W
6 wan)the wen($). permanent -or DTemporary I��) Sig ofcea weu � Dam
Bysig-CAirform,I ha*--fyrha dwwego)was(wn)awam—ditammdmfoewtth
7.Is this a repair to an mating welb, Dyes or MPI' 15AArAC 02C.01W cr 15AArAC 02C.02W Meta C mVuc w Stmammds and dw a eapy
If$dr ba rgaaM,�II aabwwn weII amaasaeaovr 8fareimiaa and uplmn the naaa:ofthe aft xcrordhas been provided m the weII owner.„c
,rpmrro t'21 r+mmJsmuan ormr*ebA*Vr1hfrfiVm 23.Sits diagram or addtional well det dlx
You may use the back of this page to pmvide additional vdt ooashu dm info
S.For GeopcobrlDPT or Closed-Loop Geothermal Wens having the same (add`Sec Over'in Rematim Boxy You may also attach additional pages if neeeasety.
oottafzncdM a*1 GW 1 ismaded.Tadimite TOTAL NUMBER of wells
dnlled: 24.SBBMrITAL P617RUC IONS
9.Total we depth below lam sarface:1 3 U par=&We-e&bwa &pdeTf�am-3C200'-d2@1M Submit this GW-1 within30 days of well completion per the felto�rIDg:
l of 24a. For All Wells- Original!form to Division of Wata Rwocaoes (DWR),
10.Slade water Level below top v A) mP=es=g Unit,1617 MSC,Raleigh,NC 27699-1617
Iywatw1esel to abow acerb,.used"+;/�
1L Borehole diameter: 24h For Infection Kam copy to DWI ITndagoumd Ida Cocnol(NC)
L n Pmgrmm,1636 MSC,Raleigh,NC 27699-1636
12 Well eonstraetion method: 01 Q!23-- /.}-V— 24c.For Water SaDoly and Op��'.Loop Gsot�r W—Rdarn WeRw Cagy to the
(Le.am raw°y,a1At,duem1um%em-) =mty envaonmaR neacm aepa tneut aS tbe 0ounty vvuIIc msmued
FOR WATER SUPPLY WELLS ONLY: 14d For Water Wells I over 1 GPD:Copy to.DWR,CCPCUA
Permit Pmpam,1611 MSC, 1 11
13a.Yield(gp* '4 1 Method of tesC {
l3h Dlsbfeetlon typt» Amount: Z ��
Form GW-1 D Nortfi Caroliaa D.gm=ct of PnvaowmwW Qm1ity-Division of Water Res=,= Ravisod 64-2018