GW1-2021-05777_Well Construction - GW1_20211015

WELL CONSTRUCTION RECQ (GW-1) For Intesnal Use Only:
L Well Contactor Information: r j•
LS JR G ti C -.14.WA MZCRM... _
host To arsoN
wencamo rx,me s`'y` • '�5 R" 20 o
tz si .
Newene cmIis=2ionN=mber „,'; ; .,c.., MOUTRReaslrrts wd�oi;Lu=
FRost To aresssrsa 7mczmm atsT�iet..,
Nam (.. ' O �V O ;1S INII M CASMOB TOBatG '•_' "'
s.Wen ComMwdon Permit#: P w a at, F To I DI&BERM lzmc n
rrsr an app�xble vsll aerabretla,e pma:lts(ir we caraay.Sma;varrma:t�� a� ffL
-7 3, & y I/,y I`
3.wen use(awkwen user `i0"7 0 0 5 S l S S �f $ R _
witersnppywen: uv. r:: _ -.:-.,..��-r:- _ ���,,:•.« :;.�:-�::��:r�� -�.-;��,.:•::...
FR M TO Dlsatar ;St.OTStza T> �S stsmtw
❑Agi=buW l]muwcipallBublia ft. �
OGeodxmal(H oozing Supply) *Fzmdeaaat Water Supply(single) >i >; m
Oladustris>/CommmuW ORcsidmtisl Wabra Supply(sbared) j&(;Rcur .• --
fl ❑Wetls>100 000 GPD FROM TO MAMIAL 1ax.►cs GwIccrffw&troaxr
Non-Water Supply Welt: o RNeait
ORecovery R f' r rl
I�sfectiop Wen: & .
❑AqufaRed=V ❑C=undw®terRem disdm ;19,SANDIGRAYSLPACS�- - „=•sue=,:a`="'�
OAgmfer Storage and Recovery 13sdk try Barrier FR M TO aA32mB®
OAquifor Test ,0-swMwaber Drainage .$ &
DEMmimeclat Teebnology ❑Subsidmoe Control $ S
OGeodmnail(Closed Loop) ❑Tracer -20:-111T>7 Tsivr_LOG(air eh`ad _
❑GeothemsalMeamg/C'mlingReam) ❑ '0d=( under421Remadm) FROM it TO assc rlox arilnet -...sb%eft
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4.Date Well(s)Completed: 0-1'�•Z Well ID# ft R
�.
Sa.Wen Location: $
06 Va i m!3 a, I\A e hd ez - ,z
Fao3t,/O NEW tFrei fry Do(ifapp&aKe)�R)
&. 67 R�cc o r Rol (061 /V Coal - 0d & R
P*siealAd&m Cis.sadZip R 8
LA rV)
z;;;y i Fmeel rde —Na(PIN)
Sb.IA*ade pad loq6tade in depws/minateduconds or decimal degrees
CrfweII Sell.Coe ladlong a so>5rieat} 22.Cerfifi 'oa: hop
jew
6.Ware)the wen(s): Egermanent -or ❑Temporary Sine ofcQasea oval Dace
Bysigfmg =rafytixa6c—Uo)warti-v)oorcm-da wcwfrh -
7.Is this a repair t+o an e3dsting weM' t t1Yns or MW ISANCAC 02C.0100 ar 15AAC C 02C.0200 well Covw-c mw Saadw*and dwe copy
Ijddr 8 a rgelr,�II o�ebwrn wrll 000ao-raWaa yrfora�mr and cplcbr the naacc ofrhe ofrhfs nromdhas brat provided m rJu�eII mmo,,,5
,Vatr wdw#21 nm ark saaran or on the b=tof#-fame- 23,Site diagt'am or ad&donal wen def&.
S.For Geoprobe/DPT or Closed-Loop Geothermal Wens having the same You may nse the back of this page to provide additional wen oonslruc6=i 6
oonswiction,only 1 GW 1 is needed.Indic'�e TOTAL NUMBER of wells (add'See ovee m R=adm Box}You may also attach sdditionsl pages ff neoeasory.
eluded: 24.SUBMITTAL IxSTRUCTIONS
9.Totalwen depth belowbtW surface:
aQ ' A) Submit this GVV-i within 30 days of wen completion per the fonowbV
Forasdaok w,&Z r aff&pla fdl�mu(—Vk-3(o�00'and 2( 1Off)
Q 24s. For An Wdis: 06&4 fora to DivWca of Water Rasaaoaa (DW4
10.Static water Ivvd below top of casing: A) 1mfi- atim Pig Unit 1617,MSC,Raleigh,NC 276WI617
If aa<erlaPduabvwaaabt:zw
1L Borehole diameter. G {m.) 24b.For Iniection Wens:Copy to DWR,Undagotmd Caouol(IUC)n Propma,1636 MSC,Raleigh,NC 27699-1636
12.Welt construction method: 1� 1c h,— A-e- 24,For Water Supply and Orpen-Loop Geothermal Rellm Wetly copy to the
Cie-CW4 roeQy,Oda%aegP01%ctr-) county envommenW hmn deperbnent of Inc coa�y vw"MAthmm a�—auw
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells prodncm¢over 100.00D Gl'D:Copy to.DWR,CCPCUA
Permit Program,l 11 C,Ralet 99-1�11
�,y�(gp� Method of test:
13L Didnfeetion type: Amomri: 12 � 4
Form Gw-1 (D Nardi Camlma Depaua ofEm*onmeomi Qoatuy-Divmon of Wawa Resaiaxs Revised 6.6.2018