GW1-2021-04592_Well Construction - GW1_20210429

WELL eONMUMON REM GW-1 For dal Use Onty: '
L Well Contractor Information: j
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FROM TO I D)SCRWrMN
Well Conta=Name fL' ti
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NC Well Cat N,anber Ls..OU1TRCASM farmnior css�:ve� ORrat!>SR
FROM TO DIrEa TffiC!n.'R48 MAiERiAL "
1/1 ✓� f� ft m
CampesyNamc 36.XNNERCA31NGMORT73B1BiG
2.Well Constracd.Permit#: _ FROM I To I DI&MEM rI TMCKNM
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LLrtaII appH�ble,vrJl uaatrnrtlmr permus vIG F ry vm �� 41 A 5 & S;F isin
3.Well Use(check wen use): R x
Water Supply WeIL•
FROMI TO - DIANZM ISLOYSI M •1 MA ERML
OAgrigdbual OMtmicipaVPublic R m
OCreo&ermal(Heatan�Supply) .tSmiential Water Supply(single) R g in
OIndustriwCommercial OR=&ntW Water Supply(shaved) .IS
fl on , OWells>100,000GPD FROM TO 'MATEMAL lMMoD&ehtotmr
Non-Water supply well• , 3' R i e-c x t d
OMMbMing Mwovery R & I G /P ( tj ,. i
Injection Welk- ELK
OAquifer Recharge OCaoundwater Remediation
ill SANDIGWAVELPACK(iriii
OAgmfea Storage and Recovery OSalinity Barrier FRM TO MATffiwAL ZMACt�PFMURM r_
OAquifier Test .OStormwater Dminage It
OExperimeadaI Technology ❑Subsidence Coa rol R
OGeothemal(Closed Loop) 01racer
2a.DBILS Il�IG F.Ot'.stlatii ddiBm®atsLeetr'id
OGeoth=W(SeatinglCoolingR�etum OOther(explain wader#21 Rom) MM To :D�aoN ar<lh�ek ere)
4.Date Wells)Completed: 4-1 wen M# R
5a.Wen Location: $ R — ht r+m aW
h ��/ ,C• 2 0Z
�e rr,. Sw arty.,:, � s
W l l!r ]G u i"t L►.� ft R q,•
FhysiralAdrhess,City id* ft. t?
Comity, Parcelldendficatkallo-OW 2 9 UZI
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5b.Latitude and longitude in degives/minates/seconds or decimal degrees:
ofwen5eid,oar>adtMiss ) 22.Certification inS�ll�.3D R cj8wron
3� . �.. N. 81 . 16' . - W
6 1s(are)the well(s): �ermanent or OTemporary f! G 0' sigaanne ofC WenCamracmr Date
Bysigabg8asjbrm,l hereby�y LAW dx wzUfs)w=(wav)awavamd 3s acwrdww wa
7.Ts this a repair to an en-sting wen:' 'DYes or Wei 15.4IJCRC 02C:0100 or ISANGIC 0IC.0200 iYtII CmvvcvmSasalmrh mid that a cop
Ifd�t is a rep�zfr.,�II ova lamm well avraarattan arfOrnaaIIon mid eaplarii the naaar afthe of Fins record has oem pmvias to me Wei owrKr.
repaer wdo 021 remmks searlon or on dx bark of d=fami
23.Site diagram or additional well detour:
8.For Geoprobe/DPT or Closed-Loop Geothermal Webs having t same You may use the back of this page to provide additional sell construction info
construction,only 1 GW 1 is needed. Eodicite,TOTAL MJMBER of wens (add'See Over in Reuel s Box}You may also attach additional peter if Thecessary
dnUed: 24.SIIBm TTAL INSIRUCITONS
9.Total well depth below land surface: (ft) Submit this GW 1 within 30 days of well completion per the fenowing:
Forsadapk welts Liar aff depth#',O�c(—nple-?@200'mud 2@101 )
10.Static water Level 242. For An Wens: Original fors to Division. of Water Resources (DWR
v below top of`ela/sing / 7 l3 (�) ��on ping Unik,1617 MSC,Raleigh,NC 27699-1617
lerl is above
1L Borehole diameter: /` a jm) 24b.For Injection Wells Copy to DWR,Undergrormd by-ion Control(NC
LL /� Program,.1636 MSC,Raleigh,NC 27699-1636
11 well COWWaction method: 'l 24c.For Water Supply and gW&Loog Geoffiermal Return Went Copy to th
(ie.-*M rotary,aalik dived posh,err-) county environmental health department otMe Cormry where MOP'led
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells n=educiaa over 100.000 Copy to.DWR,CCPCU.,
13a.Yield(gpm) Method of tesh Pezattt �'1611 MSC;Raleigh,NC 276 I611
13b.Disinfection type: Amount: -
i
I.
Form OW-1 Naafi Carolina Dep=m=ofErrviror mmrat Quality-Division of Water Resmz= Revised 6-6r201