GW1-2021-04507_Well Construction - GW1_20210429

WELL Q06—PU RUMON REM (GW,-1) Fara�al vse Only: �-
L Wen Costraetor Iffirmation:
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Well Contractor Name FBOM TO :!I DESCRUfiM
353 s 50 a°° R !
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NC Wen cat6tor Cemf=dm Number
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3.Well Use(cheek wen user R R
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OC. l(HeatmViCoolmg Supply) -0midemial Wags Supply(sinee)
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Injection wed:
O >&AqurReclxV OGrotmdwaterRemediation & R
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4.Date WQ(s)Completed: 4_1 q _ I Well m# & &
Ss.Well Location: & &
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Physical Addles%Crty,trod* R R - u -2 9 —
cmmtyPazeelld�tionNo.(D Inform, ion
Sh.Latitude dad longitade in degraw'mieatalseconds or detdmal degrees:
ofweu field dire Lafloag is suf ) 22.Certificadom —
G.Is(are)the wed(s): Orm__._sent or OTemporary 1 5 9 a' S- en Da>z
ByslgmtSdusfara;l hoeby eeatifytl�a the wet!(sJ was(were)Qoraazwaadinaaov>dmeoewit
7•Is this a repair to an easting wed:- •aYes or ffN-o ISAIVCIC 02C'0100 or ISANC4C 02C.0200 tt'eII Cgnsntces n&,,%dt and dw o avp
IVdfft is a tqa&X cte,b--will murruadan mform=m and esplabs the naaoe of the of this rramd has Goa pmvidod io ate sseII owner
tspatr wider 621 rmwb section oron thebael:oftltisforai
23.She diagram or additional well de6u7s:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having fhe same Yon may use fhe back of this page tD provide additiaOal well constzuctien info
cmmftucdM Q*I GW 1 is needed &Ucke TOTAL NUMBER of weds (add'm Ovee m Remarks B=J You may also Mach additiaasl pages if mmazy
drilled:
/- 24.SIIBMITI'ALIl�ISTRUCTIOPiS
9.Total wed depth below land surface 'A/w -
FornmltlFTe wa&&w aU dgda ff�erem(--FFte-3@200•-,.d 2@100� (ft) Snbmit this GW-1 within 30 days of well completion per the fgnowiag:
10.Static water level below top of caidnL, G d (R) 24a. For All Wells: original fOms to Divisim of Waft Res a (DWR,
Ifwmtr teal ve is abo =;ice,=-+- b*rmaIIon Unit 1617 MSC,Raleigh,NC 27699-1617
1L Borehole diameter. t ,l
a {m.) 24b.For Infection Weds:Copy to DWR,Undagotmd lnjecf3m Control(iLTC
pm ram,1636 MSCy Raleigh,NC 27699-1636
11 Welt cumft ctiea method:�p�d 4.. A 24c.For Water Su add Loo
CLG - ,cab1S ditxt posh ate.) CaeQljM1 Retard Wills:Copy tD th
cot*envmme=heaith deparbnerdof ine mmfy vibsre MsQMv
FOR WATER SUPPLY WELLS ONLY:
24d.For Water WeRs oroducia¢over 1 GPD•COPY to.DWR,CCPCU,
M&Yfeld($P� ,�� Method of test: Pamu Pmgam MS
,I611 C,IRatetg I I,NC 27699-16I 1
13b.Disinfection type: Amount:
Fo:m OW-1 ' Nadi Carolina Depattmmt Qm*_Division of Water Res=es
Revisod6.6-201