GW1-2021-00287_Well Construction - GW1_20211213

WELL CONST UMON ItECO rGW_ll For Internal Use Onty:
1.Well Contractor Information: —
L � -
�U 14.WATER T.ONFS
Well Caaaacau Name FROM To JDE542WrION
353S oR 3 `tC) -
NC WeIl Cozy Cavficarion Number R fLI&OUTER CASOG fog n> d weM OR Lim
le....:;
FROM TODIAMSITE: 'lamcompaq ... MA2LRiAL
fL TO
is
Y Name
DC G 16.II•IIdER CASING OR TQF3IVG tfeL—behciail
�J of J _ �2.Well Construction Parnell k: Mont ro iirer+m�r -tmmsmy -,�e�sAIZIList '-
Ltv all cppHaabLe,will earn-v cdon psmdst�2e WC Cowvy,StatR Yar anae ere) fL fL 5 7/l! i
_ h D
3.Well Use(cheek well use): R R ia.
Water Supply WeIL• 17.SCRSffiv - 4
a: y'. r
FROM TO DIAMSPSB: SL(rI SII� T - MATERIAL
�� Mtmicipal/Public R
R in.
OGeod—al(Heatng/Coolmg Supply) Residental Water Supply(single) g ft
Cladustrial/Commercial Residential Water Supply(shared) IS.GROUT
O .on ❑Wells>100000GPD FROM TO MA tAn CZa�7rMSIHdDtdMotnrr
Non-Water Supply Wen: fLft �—
�Moniiming
QRDfoVei?' a fLInjection WeIL• +,1 l
OAgvifsr Recharge OGroumdwater Remediation R R
OAgttila Storage and Recovery .19.SAXD/GRAVSL PACK d
emery DSalinilyBerrier FROM TO
MA�RAl, IIItPiAt�@frll<<�OD
DAquifer Test (]Statmwaler Drainage $ EEE
C3Rq-imeaml T�ology ❑Subsidence Control tt _
coeod=mai(Closed Loop) ❑Tracer `20:DRIIS ING LOG attach idditiwril ihieb R•—
❑Gent sl(Hestmg/Cooling Realm) ❑Other(explain under#21 Remarks FROM TO DffiCRI ft. R MON wio ,.i4k u as
4.Date Wei1(s)Completed: l Z- 3•l Well IDO IL ft —
Sa-Well Location: R ft 2
R fL
Famlay/Owwr 14me Facility EN(ifapphcable) ft ft —
f' R _
Pbysial TA&-"%tdy. kzip fL R
2L REMARKS
C Pz cel Ide=r==n No.(PIN)
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees: _
(ifW'MU field,one lavlong is sufficiew) 22.Certification:
_3 l 22' N S� S3 ' 30 '" W
6.Is(are)the wen(s): OPermanent or OTemporary 1 I (] Sigoanm well ca=..ior
� BJ'ngvrg thuforn;I herelry•earafy liar the nrll(s)eras(irefa)carcvuetrd th aetmrlorror smh
7.Is this a repair to an existing well•- Q.YL or 8fta I s 4 h^RC 02C.0100 x 1 A iriaC 02C.0200,7u7 Cons rater 3 a?d titer a copy
Ifrhts 1:o rspai�fill we bwrn .e11 umsmsoeamr a�rmaaart and elan rJx anon of slue of this ward has beers pro,ided to the-ll 7wn .
rtpctr sondes 921 r w=b secttan or on the back of this form
23.Site diagram or additioaal well detalls:
S.For Gsoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional vcil conshvciJca info
corstruaron,only 1 GW 1 is needed Iadidt--TOTAL NUMBER of wells (add'See Over'in Remarks Boxy You may also attach additional pages if nemagery.
dulled:
24.SUBMITTAL L?1 MUMOPtS
9.Total well depth below land surface: J L4 ft
For muldple..e11,Lsr all dapda r'atf e?ew(example-3 a200•and 2@100� ( _� Submit this GW-1 within 30 days of well completion per the followinig
10.Static water level below top of casixtg: 2 0 (�) 24L For All Wells: Original form to Division of Water Rw=t w (DWR),
If�.n+er lepd is above castg;� + laformation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
24b.For Injection Went to 11.Borehole diameter. L /8 �'m.) Copy DWR,Undergotmd Injection Control(IIIC)
11 nn Program,1636 MSC,Raleigh,NC 27699-1636
12.Well contraction method: 2 h'i 24c.For Wittier Supply and Open-LoopGeothermal Rdm Wens:Copy to the
(ie auger,rotary,oabk dirsctpush,ac.)
county eavirnnm health epaztrncir there e county
FOR WATER SUPPLY WELLS ONLY: 24d.For Water WeI13 producing over 1 GPD:Copy 0 DWR,CCPCJA
13a.Yield(Ypm) Method of test
Permit Progam,1611 MSC,Raleigh, . CC 2o76�611
13b.Distnfee Amount:
tioa type:
Form GW-1 North Carolina Department of Envitonmestal Qtaatityy-Division of Warr Resoraces Revised 6-6-2018