GW1-2021-07654_Well Construction - GW1_20211214

WELL CONSTRUCTION RE!Q (GW-n For Iuwmal Use Only:
1.Well Contractor Information:
heQ�lj
L . S . .14.WATMZOM
wenCo°namarName FROM M DESCRIPTION
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NC Wen CaaCractor CadBcatioa Nraba ]S,ODTER C'ASRYG t oshii6l `eel weQs OR LII�I�t .r•7.. ..
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Coa�aep Nam iI&IRNONMMCASDY OR T UUNG
2.Weil construction Permit tt: PlvoM ' � Drensursa TtnMINEsS
fJtr aU tip Uoable wail osranvetron parndra tLa LUG CWvW.Smaa Ymfaaaa era) + fR R y,'d! hr i �, ✓V
3.Well Use(check well use): _ R R is
Water Supply Wet +-+^..,.,_. Y �. _,.' ,., ;,t.,... , .,•.
/I7SWl\YW\t .:'.Ih.N KP ITx•.:Y�Y•1.:V!: ..LLia%.... ^i.?.�.iye'1 i.+p�i .•.
PROM TO I DIAMr= SLOTSM I TKKX Q98 I MATXRJAL
OAgriarhutel OM cipdU lic R R tM.!
OGeothetmal(HeapnwCoo�B Supply) ,.l idemtial Wafer Supply(single) t R tin
OlodustriaUCommeroial OResidential Water Supply(shmed)
9 OWells>100,WO GPD YNOM TO MATERIAL N437A _--MR111CM&AMOUNT
No>a-Water Supplywea R 3._2 'R. !l f Ca t •C_.
OM ORecovery R R ecdon W r FIT A
•
OAquibr Recharge OGrouadwater Remedistion R R
OAgrrifar Storage and Recovery19 SAND/GRAV.EL PACE'8""
OSalinity Barrier PROM I ro MATERIAL zm.
NZEM
OAquiferTest OStorm ixerDrainage $• R'DEgwimental Tecbnology ❑Subsideme Control R R
Otleath�al(ClosedLoop) ❑Tracer x 3,O20:DRMLJMGG aft" 'ditiobWArb$kb'�"If :.: •.:;,:: :'•.
OCieothesmal , Return OOther under421 Remarks PROM TO DUCRIF.WN wb seah a ae.
4.Date Wq0)Completed: Z—L'ZI WeD 1D# ft R
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5a,Well Location: R R t,t v— T h ns
R R ,� •
Fao:lilY'/Oan:N� Facility D#(ifoppticable) R R,
PIMIQAJ1ddce1a��xCiw. drV ft.
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Coimky Pa°elldamffioadoallo(PIId)
5b.Latitude dlo ,r":�srrVGliNI'
ap longitude In degrees/minatea/aeconda or degrees:
ofwen wk aloe hdlong is soffieift) ' 22.Certification:
319 ' IS'' 5.7' N �tb , . 5-7 W
6.ls(are)the well(s): ❑Permanent -or OTemporary 2 g' °D° Nth
Doe
� By A8�8�+1�RlherebyeartlJythorrhenall(s)wm(wele)eonrasmadar000mdmuswtVr
7.D this a repair to an existing we1L•, •Oyes or &QI ISANG4C 02C.'0100 or 15ANUC 02C.0100 Weg Qn*:cd=S w dmdr o,d din c copy
{/d�a L a saw ftII o,�baern wf!emaaa.enwr es�6ra mio»mad asPtaas rhs!a�oae ofrhr 4f rids neoostdAei b ar p.wldsd m rlrs,.+D e,n,o V.
rep&wxfsr#31 ramarb swron or an the b=k of rhfsjorm 23.Site diagram or additioffil well details:
S.For Gcopcobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well omuhuebon info
conatarctiea,only I OW-1 isaneoded. Iadicdfa TOTAL NUMBER of wells (add'Sce Over in Ramim Box).You may also attach additional pages if necessary.
tea 24.SUBMITTAL IIdS1RUCTIONS
9.Total well depth below land surface: (tt)
For sndap/s wWk&r oll dgda 0r�von(ao Wk-3@200'an d 2®100') • ) Submit this GW-1 within 30 days of well completion per the followhW.
10.Static water level below top of eaa@rg: too (R) 24L For All Wells: Original form to Division of Water Rworaoes (DM
Ietiwt r1 i�ss +, Information Processing Unit,1617 MSC,Raleigh,NC 27699.1617
/ e Infection f WDx For I 24b. ne
11.Borehole diameter: � {fn.) Coy,to DWR,Underground injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
IL Well Construction method: D }3 rn •r" 24c.For Water SuoDls and 0 'a-LooD Geothermal Retmna�VeDar Copy tD the
(Le.aagem rotay,xbh,daect pasb,a%) coudi- envvonmeniak nearm aeparmimt os me co ffi wneim mm a
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells rodu '{ over 100.M M.Copy to•DWR,C=A
27699-1611
Va.Yield(gpm) �`!- Method of test: rr P° ��1 if C, eig ,�IGT
b
13b.Dldnkcdoa type:_.. Amount:
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PC=GW-1' N°sdr Carolina DTarcac t ofSmaoom aW QW4•Div=n of Wawr Resou= Revised 66.2018