GW1-2021-04691_Well Construction - GW1_20210521

i
WELL eONSTRUMON (GW-1) V For btemal Use Only: �.
L Well Contractor Information: -
<J . M - IV !n t;: 79 .14.WATERZONFS... _
well Ca Name j o; +- '° PROM TO 1 DFSCRRU7M
300 IL o°
2 ft ft
NC wen Co Catificatim Nwaber H 1
t l)DTBRCAS�IG timdtrc�ad wall)t]R IdIM'
••
� T9 DfAMSlFB M!Tv.QUL
FROM
V �.11Y1'7G.vV { i3i t'C `.� 5i j1 ft fi' m.
C=* Nam Y V 1♦ ..
ii6.MMCASQI(TURT�iG
2.Well Construction Permit#: 101 L •2 U y C, FIRM To 1 DTeNOCva yy`�Du►7�Lu.
Lsr a¢appS=ble va=W?vaa=pmx is rue-MC ComaY•Smtp-Vw==-.ua) .{. f: q It S 71Y is -I M,Cti
3.Weil Use(check wen use): ft ft
Wafer Supply Welt: I;
PROM I TO - DIAMSrJ3B SUMSEM :'ffiCiCOiSS vAMU
OAgdculturd OMsmicipaVPublic ft fi fn
OGeo9earta1(Hea�Coohng Supply) ideadal Watts Supply(single) & ft is
ObdustriaYCammercial OResidential Wafer Supply(shared)
131hisation OWells>100,000GPD FROM TO
MATEME&L EMPLACEMEWMEMOD&AMOURr
Noh-Water Supply Welk O ft it /v Kt M i �ej
OMCDrtorirtg 1ORecovery ft ft n0� �r e•
Injection well: ft ft
OAquifea Recharge OGroimdwater Remediation
%19 SANDIGWAVSLPACSxf" '� ''w i ice: s: F:'•r
OAgmhr Stnraga and Recovery I OSalinity Barrier FROM TO MAMMAL TlMPfACII1ltQfrDICrHBD .�
OAquifcrTest OSmsmwalerDrainage ft ft
OBgaimental Teclmology OSubsidenoe C n rat it ft
OGeo wmrai(ClosedLoop) OTracer 2o'r)iYRS]Nr_LOG e}tatlriddm'mhtih&*ff_ - �_^-::-tea:.
OGeat#x�ai(Heatzng/Coo Retain) 1 00dwr(explain under#21 Remadrs) PttDM ft To $ DESCHI.n0N(e*CkffdftMasd(rvet aa.)
4.Date Wens)Completed: t- ZI Well ID# ft ft
Sa.Well ft ft Location: L.-k,e bra C P.. -/�Y
-Z-acH ft
lwmow,
ft
Lz ctir i
i ,dOwnae- - Ra�IN fa;VEcabie) & 8
n611-07- It ft
Physicv1 0tY sad* C- n.t—/ ft ft
Caamr Finkel I on No.(FIN)
5b.Latitude and longitude in d nteslseconds or dechal degrees:
(ifwen field,we iaolm is safes) I 22.Certifimi" o:
d�
36' ! 5i ' 32- N 91G ' .Si ' SG w
6.Is(are)the wefl(s): i3Per Mat` orI m.,ap rar9 13 7-0 ' S*==of 4W&edWeUCQnft3= DmIL_. g�sigmrgd2s I heRby curdy 8atr dx�re11(a)�(wav)eorav=md M a=mdareoe ra
7.Is this a repay to Sa eastnug wen '� ;. or flNo 15ANCAC 02C:0100 m-15ANCAC 02C.0200 fYeII Cp="-rr Strad-%*oral dint a aop
!f dds is a repro fill osd brown treII oarrsorxvfo� and esplabr dre roorrae ofdre of this tumid has ben provided w dw wnU ownv
x redo#21 reatants saetlort or on die bmE dasform 23.Site diagram or additional well details.
S.For GeoprobeMPr or Closed-Loop GI thermal Wens havmg the same You may use the back of this page to provide additional aen oonstructiaa ir&
suction,only 1 GW 1 is needed. Padre TOTAL NUMBER of wells (add See Over'm Remarim BoxJ Yau may also athaoh additional pages if nay
dnIled 24.SUBMITTAL MMUC(TONS
9.Total well depth below land snrfate: Lf U r (ft)
For oBt*wells 1w all dada rjdferern(—Tle-3@200•mid 2@100� Submit this GW-1 widbm 30 days of well completion per the fallowing:
10.Static water keel below to of `p d (R) 24s. For All Weds Original form to Division of Water Rtswar es (DWR
llo.St ti ei a stave� top zee , (/� won Processing Unit,1617 MSC,Raleigb,NC 27699L1617
1L Borehole diameter. G /b {m.) 24b.For 7nlection Wens:''Copy to MM,Undergroiard bVectioa Coahol(IUC
Program,1636 MSC,Raleigh;NC 27699-1636
11 Well eomstraetioa method: C}3 24c.For Water SnoDt9 and Ouea-IM GeotT;vm AR-turn Weft Copy t)th
Cie.a r�rr,rotary,cawaeap� cor M) mty envanrrmentai hearm department ai the County viha MS=ed
FoR WATER SUPPLY WELLS 24d.For water wells nreduc>ma over 100.400 GPD:Copy to.DWR,CCPCUe
/1,t Pwmft Pmgram,1611 MSC,Raleigh,NC 27699-16I 1
13a.Yield(� . 15 2112efhod of tusk /'�
13it Disinfection type: �"}71� I Amount I 0
i -
FoMn OW-1 N,&C=b,,Dvu==ofFm=nm=tal QoaW-Divi m ofwater Res== Revised 6.6-201