GW1-2021-07644_Well Construction - GW1_20211201

WEAL CO,NSTRUCnON RECORD(GW-1) For internal Use Only:
1.well Corr Ishrmatloe;
—8c ti 1 7 N
seiner To Da:3Ca1rnaa
47'D E7 ft. ft. -
NC Well Comnctor Cestificatian Number Bar
�--------Mi
110
ft. n. ti.y NameOT
2.wen Construction Permit k: L.�� �?'�f m!7ft.
o>�►t�eicreat tBttnc.
urt all a�dA-bk wdl—trucd-pesmw C.e.U1C•Cowrey,state.Varta�e,ear.) ft
3.Well Use(cbsek well use): Va r- fud
waxer Supply WeO: t�wm To DtAsf nk tli al f c Tmi+ctuafst�ATTf�W.
Agricultural 13MtmicipailPublic fL ft.
Geothermal(Heeting/Cooling Supply) , Residential Water Supply(single) R ft to
Indus<diaUCotrrmoacial Residential Water Supply(shared)
ILSE= l
Inizatioll ram To MA aet�t.ACAKI err WTlsoon�AMGinrr
Nita-W�Supply well: ft. E
Rt+covery � R
for Recheigt �Gtvuudwatra Remodiatiort _
fL
fL.
Aquifer Stooge and Raeavery Salinity Barrier mom TO MATERU BM�r ACFI KS A Oa
Aquifer Test D Swrmwater Drainage ft• ft,
averimatal Technoiogy [3Subsidvrx*Control ft. R -
(Closed Loop) Tracer A
Geothermal tin Return) Other lain under tr21 Reatari s PROM TO DeeCft>tt9or astir eattlraeJa ere
ft. R
4.Deb Wells)C4supleWdah&aW) Wen wo� <„f.
Sa:We1f Locatloa•
� a J A /l
FrcititylOwoer Naive �Facility 1DN(if appikabie) :ft• ft ' ! J1
ft. y
Ptiy l id&vis,e. and zip
may, Pavelidewff"tionNo.MN) INFCRW;I'..H"ROCESSING U I7
Sb.Latitude and longitude In degraWminutesiswonds or decimal degrees:
(if well field,ow w4ons is sufficient) 22.Certilleatiog:
6.b(am)the wea(sIMTermanent or 13Temporary Sipsome ofCemfiod We!!Conbfictdr
!ry Signhtg rhra jornr 1 hereby ccrhfy that tie WVU(s)wad(way)canrmacfed-a acco.dafty
7.Is this a repair to an existing well: ®Yea or a wui 15A NC tC 02C.0100 or 1 SA NCAC 02C.0200 Well Condanrofion Swwardd and that a
If A&isa npatr,)Vl out brown wdl constrtoc&M bi(orm axon explain the reams Of& mpy of thin record has ban provided to she w it owuw,
nrpatr weds►421 tvmarka sm*m or on the back of thir)4rrm. 23..Sift diagram or additional well dc9ttite:
8.For G.eoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,aril 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:-
SL��TTA>_.IFdSTRUCTIONt. ,
9.Total wag depth below land surface: _ fota�n within 30 days For n W*k►sells Use aU depths(fd(fdrwrt(exewrle-3®200'wrd 2@1001 24a .For A)�y ells• Submit this of cam plesion of well
cwlat:uction'to the following:'
1A.tltatlx water level below:loplof ayslog. e (tQ,) Dfvtdon of 1Haicr Raourceop Information U
wear tend is abo►a caritg t►re. l J 1617_Maul Setvloe Centerr.Rakigh,NC.2 7,.
G 1l aorvdoois dirroeeoer ,.,�
�-'-- --(�) 24b.1
6r Latettf%4 W&r .In,additiun to,
ftnding.the.
form:to the addrtr+s in
74a
p
12.we®osnurrietlon®etlti►d: (, above,also submit one copy of this!form within 30 days of completion of well
construction toeow the flloin
(i.e:eatger,i6pry;:orbk direct push,etc:) g'
DWMMon'of Water Risoorc k UaditV'mnd Injection Controi Dram,
FOR WATER SUPPLY WELLS ONLY: '1636 Mail Service Cei ter,RaielgN NC 27699-1636
13a.Yield(gplir) 4 Method of tat: 24c.Par Water Suualy&inlectloa W in addition to sending the form to
the vMrasa(es) above, also submit f orte copy of this foam within 30 days of
13b.Dideetleedon type: Amount: completion of well construction to the county health dapttnmc of the county
where conetntctod.
Form aw-1 North C—h-Dvperwwm ofHovimnmentai Quality-(Division of Water Resources t RmiW 2.22-2016
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