GW1-2021-05555_Well Construction - GW1_20211013

VPELL CONSTRUCTION RECQ (GW-Il For Im ernal Use Only
i.Wall Contractor Iaforma>ios:
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3.Wen Use(checkwen user R R ie
Water Supply Wen:
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DGeothermal(He�CoolmB Supply) al Water Supply(smee)Water Supply(shared)
II DWetls>100,000 GPD FROM To _MATMU46L I as XACZIGMW"a�
Nonmater Supply Wdl: D R 2 3 YLR /feat f f
ORccov«y R R rf'l�a
�jection Wes:IIMmitoratg
DAquifer Rec� . IIGrotmdwaWRemediation fL ,
OAgmhrStwW and R=-ry II Battier FROM
9fQ �.-.�..
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DA4uifar Test .OStorarwaW Drainage R R
DEcpaimmtel Tahnalow ❑Subsidence Control R ft
Otlaotbermal(Closed Loop) OTracer =X-DRIId M FAG
IIGeothemalMeatmaCcolmgRetma) 130th=(vgAamuoder921Remedm) Fsona To DffiG'81Fl70N .zaet N
R R
4.Date wens)completed: ! — LI Wen Lm# R R '7 SS
Sa.Well Location: ffi R
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F Fae:2ity M#(ifggfioabk) R R
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Adtit:em City,md2ap R R ,
Sur(11 2L'-REMAM "
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Sb.Latitude and longitude in degmeslmmutesiseconds or decimal degrees:
ce-al iel4—'Inqm is zoff ) 21 Certification
361 4-011 N b ' `C� • .57 ' W _ 1 0—g 'LI
D' sigomae wen Dare
6 Is(are)the well(s): ermaaent yr DTemporary t
t
Bysigfmigthisfor�I harby tasty rhardte veQ(s)vas(Brae)eaaaremdbsa�s�avdonaevuh
7.D this a repair to an ears ft wdt- •13Yes or Mlo ISANCAC 01C.0100 or ISR NC4C 01C.02M Writ Covuaraert n Smmdmdr ant dor a copy
Ifthfs sa rspatr,,¢ll Dee Morn yell cmatrrcenwr u�oramrfmi mdesptaat she n�as ofrhe of�record has beae provided m she veA��na,t
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23.Site diagram or additional well details—
S.For Geopt obeMPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional cell construction info
construction,only 1 GW 1 is needed. Indicbe TOTAL NUMBER dfwells (add`See Over'in R Box}.You may also attach additional pages if necessary.
drilled._ �J 24.SUBMITTAL MTRUCTIONS
9.Total well depth below land surface: O (K) Submit this GW 1 within 30 days of well completion per the fonosrmE:
Fora &*-e&IM agdegda a (—npk-3Qa 200'mrd 2(a I )
d 242. For All Wells- Original form to Division of Water Resotat es (DWn
I0.Static water lewd below bop of casing: ( ) kdzmadon Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If>asrerlesslisclayeads Im"i'
IL Borehole diameter. to O {m) 24b.For Injection Wells:Copy to DWII,Undagvtmd Injection Control(NC)
Pragtam,1636 MSC,Raleigh,NC 27699-1636
12.welt construction method: 1�Okaha All' 24c.For Water Sn�s and Open"Loop Geothermal Return Wells:Copy to the
CLG' i•cawd¢ectpush ) =mty eavironmemat neaten department of the county where ms�le
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing ever 1MM GPD:Copy to.DWR,CCPCUA
13a.Yidd(gp� Method of test: cI/• Permit Pmgt�,1611 G,. 94-1 I 1
L3h DLtmEeetioa types � l Amount:
!
Form GW-I North C>aoYma Dep=tmenr ofFav==mr l Qudirf-Dmwon of watts Resm=es Revered 6&2018