GW1-2021-07984_Well Construction - GW1_20211122

WELL CONSTRUCTION REQX (G D For Internal Use Only:
1.Well Contractorfo Inrmation:
. D. AI -14.W,T=Z1O0M....
well CoaaactorName FROM To ON
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NC won CoatiacoorCaaficetioaxambar - OVMCASDIG SWA&Ut-e*&% OR la= O-A, . ..
f FRDM TA DfAbErm Tfmcw= TEK"
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NtmO i� 36.RQMRQUWGOR TUBING " ,.. :.r•;�' ,.
2.wen Comtrection Permit re: .�D es�' I�-1 L "WM To Dren�rrn TOZOE s v sasTl4ttaL
LW aII qV&&bk-,fi- trvefi-pav is tit WC Cow*.SM Vwfmw%eta) R• &7.R 5 7 VIL n—
3.well Use(check well use): tL fL �
Water Supply Wen: :1.17:sCRBAt;:. v.:A�, .„+v.::.'r ��N'u, ., ;,t..f•:�:i;Y't ?,:'.'•c:
FROM TO I DUMMIM swrszm I IMMM I MATtf OL
OAgicult al OMimicipal/Public R R fro.
OGeothe:=el(Het#IpCooling Supply) raeatial Water Supply(Slagle) g &
❑ladusawcommercial Residential Water Supply(shared)
..1�.Vi�V V l'. ..u1. .t.lfi•i L::�,by •:1..
❑Wdls>100 000 GPD FROM TO MRSODIAMOUNr
Noh-water supply Wel: O R 713 R &r All <•Il
OMmitoring ORecovery R R
In/ on W •
IL R
OAgWftReebwp ❑CaoundwaterRamedWon '
Aquifer forage Recovery .481m$y -1A SAND/G1i M PACS>f a 't��;S" 9s�..r�•r r GS pia
❑ S and ❑ $orrice PROM TO MA1WtrAL 1HKPEACIII@tr
OAquiferTest OStormwam Drainage 8 R
OExperimentalTechnology OSubsideaceContol >l: R
Otleodomai(Closed Loop) OTM= r20:DMLLW1G•IAG aitieh'Sdditkhiilibadkil f " ;xn:N
OOWIfiemud @ Reonn OOtha vader#21 Rcmadcs FROM TO DZSCRW N eat neaa.et ela'
R R
4.Date Well(ti)Completed: Well Dbt R R
Sa.Well Lotadon: a3 tt. R
,�-, IJY�►Gtiru.r R R
Faa@irylgwnw Nerve I Famlity MO(Tapptieable) NUV Ti
R R
.�9 trAjrj L_ r . M l-, C R R
P1;ysicalAddreat,t�y,aadT.tp tt R ;
S(.err*j :21.'RF.�ARss•. : . :�:.
County Parcelxmdfieedon No.0mg �sr H` I I
Sb.Latitude apd longitude is degrees/mInutes/seconds or decimal degrees:
(ifvrell Sold.one Ldlong n mffimw) •, 22.Certification:
6.1s(are)the wen(s): Ar'maaent -or OTemporary L}OO► Sigaanne ofCerufied;•. ell Date
t
• BY�t�+S�fo>�Ih4�Y��YthattheneA(sj>.era(�nae)eoarvaradDnacssvrl�naevdlr
7.Is 0b a repair to an etdsting we0:P EWA or No 1SANCAC 02C:0100 or MANCAC 02C.0200 Feff Caun6umbn Saadmdt w ddwa copy
rddt Is a rapa<t,f1A tee brown wU a avuodan bebrmmtan and Zp&ft die mate of da of dds tvxmd ha:beat p oW&d m the mil aw .w
mpg&Wx&r#31 M=h seoaon or on the bad cfrhtjb m. 23.Site diagram or addftioaal well detaft
8.For Geoprobr/DPT or Closed-Loop Geothermal Wens having the same You may use the back of tbis page to provide additional well construction into
construction,a*1 GW-1 is-needed.'adicits TOTAL NUIM BER of wells (add'Sec Oven'in Remwks Box}You may also attach addldond pages jf necesay.
drtU LL '' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: T�6 t (N') Submit this GW 1 within 30 days of well completion the foilo
Forra&pk hell Ha aDdyx/a lf4*r m(amrple-3 200'mtd 2@1M Ys, mP per wing:
10.Static water level below cop of ewing: �Q (h) 242. For All Wens: Original form to Division of Water Resources (DWR).
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Information Processing Unk 1617 MSC,Raleigh,NC 27699-1617
.�vwur kw!is abow oar6,g foe
24b.For Injection MMF Copy to DWR,Undagroumd bjection Carved WC)
11.Borehole diameter. {in.) Progtant,16-M MSC,Raleigh,NC 27699-1636
12.Well construction method: R e, Z w/, ry 24c.For Water Snp*and Open=Loon Geothermal Aetttrp Wt4�Copy to the
(I*.avga,totsty,eabb>,direct pm14 eoe.) county anv=Me epartmeat camty
FOR WATER SUPPLY WELLS ONLY: M&For Water WO rodndn i Over 10 000 GPDI CApy 10.01R C=A
Pamit gi�m 1611 MSC,Raleiglt,NC 27699-1611�
13a.Yield(gpm) Cl Method of test •tom-
13b.Dishffectlon type: I Amount:_� >f ,
Form Gw-1' Nutt Carolima Depatuam of Emimomeatal Quality-Division of Water Resaaees Revised 64-2018