GW1-2021-00281_Well Construction - GW1_20211213

WELL CONSTRUCTION ECa_ (GW-1) For Internal Use Only:
1.Well Contractor Information:
L { 14.WATER ZONES —
mom TTO D4sc=v toN
wen coeetacor xame R ;0 1)ft.
5 —
353 -
R R
NC Well Co=scmr Cutificadon N®bcr 15.OUTER CASING for m�d w e1la OR LINYIi
FROM To DIA?•JS n' T YL49 ... 11SA2iAtLL
` (w ft 1 is
Name / 16.INNER CASING OR TUBING `64im'sl&ailoc a
iWell Contraction Pei mtt x U 5 K l/" FROM 11,0 D�,_�_
rauar, ,.edonR�u1GCa .sYaT;a..�a�� -{- R 5 y1 K t° —jh,•cw ►ti
3.Well Use(check well use): R R in.
Water Supply Welk ,:17.SCREEN
FROM TO DiAmrm—T SLOTS= I Tuprimm I MATERIAL
❑Agticuhvtal cipaUPutblic R R in.
OGeothemtal(x�Coolm$Shy) -❑AQ �,ri�l water Supply(sh*e) R ft m.
❑Tndustrml/Commercial ❑Residentie,water Supply(shared) la GROUT
9 on ❑Wells>100,000 GPD FROM TO �- 7
UJ, E MP1AC�Ir AM=0V 2 •o
Non-Water Supply wen 0 fz 3 r
OM sg 011ccovery ''` 7p f Y I ifnA ti
ln,ection Welh —
❑AquL*r Recharge ❑Groundwater Remediation ft ft
19.SAND/GRAVEL PACK d 0k •
OAquifes Storage and Recovery ❑Salinity Barrie _ FROM TO MAT ER[Al. IeMlIACII lC7S flQl�YD
❑Aquifer Test ❑Stosmveaier Drainage ft ft
❑Experimental Technology ❑Subsidence Control R ft
❑Geothermal(Closed Loop) ❑Tracer =20:DRILLING LOG arraeti addiaaoal iLeeti'd
❑G al(aeatm9Coolmg Return) ❑Other(explam under#21 Remarks) FROM I To DZSCRri=nox(=kr,kutwmm4 nate` ac
8. R
4.Date wea(s)Completed: 1 Z-3-2 ► Wen>D* R. R
5a.Well Location: ft. fz - Y ,StiJ
�S
Faalry/Owff Name Facility Dd(Tapplicsble) fL !t
aY-d,Ct — M2j:10,--z, M;II JZ d R R
Fbys' Address,Cry,and Zip R R
County Patel ld era No.(PIN) —
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(ifwell field,one IrAoag is sue) 22.Certification:
N �� ' S�' S " W
6.Is(are)the well(s): ermanent or :]Temporary / i ° Signature oqmeggwell cctkor Dzie
7.1,this a re / BY ng-T 9-form,l hereby--fy thar thr weA(s)was 6mm)comvu=rd nr accw%knor wah
pair to an existing well:' EIYcs or M UA NCAC 02C-01W or L'ANC4C 02C.0200 Weft Car vu=bn Sandarac old dcr a copy
if rhtr is a?qMV ft a.c bwv weU L'a 2r c6on mf,r =om and ap&dn the mare of the of thus record ha been prowded to the v+ owner.
,epa�r wdsr s21 remarb section or on the back of thrsform 23.Site diagram or additional well details:
8.For GeoprobrlDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to pro4ide additional v ell oonstuctkm info
construction,a®ly 1 GW-1 is needed.. indicate TOTAL NUMBER ofwells (add'See Over'in Remarks Boxy Y3u may also attach additional pages ifneommy.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2-Z 0 t A)
For=ddple w4s hr aU depths rfcB on(&=nple-3(c&200•and 2@100� Submit this GW-1 within 30 day,,o;`well completion per the following:
10.Static seater level bdasv top of easing: ft
24a. For All wells: Original farm to Divisiotl of Water Resotuoes (DWR}
If,aarsr Level is above�:use..+-(l ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: a (m,) 24h For Injection Wells:Copy to DWR,Underground Injection Carol(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method
lie.aim�.cable,direct push,�.) 24�For Water Snputy and OpeD-Loo�G_eother�mal Retar n Wei Copy to the
county envuormental h eparcmeai tthe camty where
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Weiler pruducing over 10 0%GM:Cagy V DWR,CCPC'UA
PMM Program.,1611 MSC,Ralei; 1 11
13a.Yield(Qp� Method of test �7'
13b.Disinfection type — Amount:
Form OW-1 North Carolina Department of InvIIoamental Quality.Division of Water Resources Revised 6-6-2018