GW1-2021-06258_Well Construction - GW1_20211123

WELL CONSIRUMON REM (GW=1)
1.Well Contractor Ilnformation:
• ►Jon •>�` d 6. %14.WATERZOI� —, ,.•I_: ... .
wen t:aonaetaName
FROM TO DFSC211MON
a`-4 1 y
'NOV 2 3 2OZI 20 6 ft' z� .
xc wen caracroreettifiatianNamber LS oDTERCASffVG s�»lud;�oRln�tt ,..r:..• ..
IDWR SECTION � FROM T8 DIOMM" $ 710CEN 39 MATEnW.
CompeayName �, , ah �r �i't7�a� m
A&ftQnMCAMG0RTVBING
2.Well Construction Permit8: ��1�1'1 FROM TO DIAMETti>< -_ ;MAM",6 '<
urau�o�le,�vaeraa,exanpe,�,rra tdG Cagy.smr�va,;ar,o�u�J , �' � ft' 3 R' S�y i0' �l,nr�t. -�-u
3.Wen Use(check wen me): l � q If R t - Th
Watsr upply wa . -.r ; �;: Ka?.:ems•= rla< _., .::_; x`�;% Ixr.^, ,.
FROM TO DIMMER I SLOTSrM ' •,TEMCIMM I MATBR14L
❑MtmicipaUPublic R S fir.
❑Geothermal(Aex4*C;ooImg Supply) ❑Residential Water Supply(single) g ft
❑InduffiiiwCOmme[eial ❑Residential Water Supply(shared)
13krigetiop ❑Wells>100 000 GPD FROM To rMATIItW, h •&AMQ
Non-Water Supply Weil: () .R ti: eater
❑Monitoring ❑Recovery R 3 tL a r41�
Infection Well: -
❑AgtuSerRechatge ❑t roundwaberRemedistion $• tt
.49.SAND/GR&VELPACf3-tf6 :'
❑Aquifer Stamp and Recovery ❑Satmity Barrier FROM I To MATER AL IMPLACEMMrMr71FeD
❑Aquifer Test ❑Stotmw iff Damage $ R
❑BperimaoW Technology ❑Subsidence Control iZ f3.
00 al(Closed Loop) ❑Tracer =20:•DRIIS.ING LUG attieli IIMI'nilidteeli'ff' ,:: '::.
❑Geothermal . eatinP/C'oo' Return ❑Other( under#21 Remadcs FROM TO)
o DBSCRipTiON cob +eiVteet etc
R R
4.Date Well(ti)Completed: f I- I wen M# R ft L/Vti L
\ �1
5a.Well Location: L t t+i 4, R i •-✓ ft. L Z Z D
0—In
- � A �„• ft. R
Famlit�y/(Ow=Name /� Facslity Do(ifapp&zWe) it.
W ,,-dU.,f�tit� Y1 � . R R
PlyYsieal Address.City,sod R R
W .ref l y .21-:REMARES.
County Pmoel Melon No."D
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
gvma Sell,one Lt/m is saPSeiew) ' 22.Certification:
6.Is(are)the wen(s): ❑PErmanent 'or ❑Temporary aft D- Z/
SignuueofCerufied; ell Data
BY08mb+8dzEsfirm Ihaebycertiify Mar dw we (s)was 6mm)emaaumdaaav=vh roevfth
7..19 this a repair to an erasting wen:, ClYis or 15A NCAC 02C:0100 or ISANCAC 02C.0200 Wed Cavuvucwn SYmidmdr mid dor a copy
!f ffrtt l:a tg�r Jill ore brown vdf aovaerraetlmt brfosarattmr mid e:�n the traaos ofthe of rids veob'd hie bear prviwrded m thi weQ owtm.�
xt &render#21 rmrmbswomt army thebmkeffform 23.Site diagram or additional well details:
S.For GeopcobcMPT or Closed-Loop Geothermal Wens having the same You may use the back of this page to provide additional vmH construction info
won,only 1 OW-1 is-needed.ladidte TOTAL of wel1r (add'See Over'in R=arb Box}.You may also&Bach additional pages if necessary.
drilled: '
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3�� 2 2 0 ft.)
Fos muWpk*#ells Ira aU depda ff&,#ben(exmarple-9Qa 200' 2@1001 N Submit this GW 1 within M days of well completion per the following:
10.Static water level below top of� (] ( 24a- For All Was: Original form to Division of Water Resources (DWR).
Jetiat �oMs „+; Information Processing Unit,1617 MSC.Raleigh,NC 27699-1617
11.Borehole diameter. /Y (m") 24b.For Infection Went Copy to DWR,Undergmnd Injection Cotrhd(IUC)
n 1636 MSC,Raleigh,NC 27699-1636
12.Wefi construction method: For Water SnDwl9 and Owen-Loon Geothermal Return Wens:Copy to the
(Le.Swer, diroRpmh,ere.) environm department County ms1s�
FOR WATER SUPPLY WELLS ONLY: For Water Wens rodncin over 100 00 GPD:Copy to.DYM CCPC(lA
13a.Yield(gpmt) o Method of test: ��>1611 C, ei 71�11�
13b;Dishifeedon type: Amount: Lt
Foam Gw-1 Z w.( Novtb Cam' ofEnvaonmemal Quality-Dmmn of Water Res=m Revised 6b-2018