GW1-2021-00445_Well Construction - GW1_20211206

WEU CO Urr IONRE -1 For.internal Use OI11y: �.
1.well Contracmr Informatio .
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2.Well Consumd1on Permit ' 16768 Hwy 268 W iiWM GSIIYGOA Drs�ar:>r ,e.•���.:
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3.well Use(chrJc well use): I $ R
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CGCO MW(iix(ing/Coolusg Supply) denu water Supply(single) R R to
❑lndusniWCommarald OResidential Water Supply(sbared)
a aWeus>lflo from OPD FROM To MAMMAL I MOIACOOMW44 iamf
Noh-water saps wen: 0tt 2.3 R �
OMonitaring ORecovery ft: R �•A
Injection WeL,
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❑❑Aqu t Rye koundwaW Remediatian R
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OAquife Storm and Recovery OSalinity Barrier FROM I To MATtMUL IMNACOOMINAa't M
OAquiferTest OStormwaLM Drainage R R
OBxpaimental Uchnalogy ❑S»bsidence Control it R
00eo&=W(Cinsed Loop) OTracer -�20.DRnJMG•LQ G attseh Idditioioit Sb"If " '
C30eothem:al , *a= 00dw under#21 Remarks i'ROM TO D ON e0b ..w eta
R R
4.Date We")Compieted: � �2� "� well MN R R
Sa.Well Lodad a: R' R r, !,.� 10L/
R ft
p Z►» K . k LOLr'C.w
Faos7ity/owner Nam (� Fadlity Ma(ir1l:
livable) & i �• �
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Cowry Paeel Ttla:dficadon Na(P>M .z+ '
iu
5b.Latitude apd loughade in degreWmhnutesluconds or decimal degrees:
(ffwell lfeld,ems ladlong is ate) G/ •' 22.Certification:
6:Is(are)the weI(s): 4ermanent. -or OTemporary �i'f3 3igoaaae ofCertiSezl• elt Dane
ByOiVd*ddsfMnI he-by ar0tho dawea(sf war(weve)cvmvumedDtaaowdmawkh
7.U this a repah to an existing welt, •QYct or QNo 15ANCAC 02C:0I00 or 13ANCAC 4?2C.0200 FeB C ubuadon SYwAM&and dw o copy
.(f dzts tr a np&,,ft[a.e bzowz well cwu&zwow##bmazton and eFlain the now*ofrhe of rhts t+eao discs been ptwldrd to db well owner
trpab zoder tJl rsnarkr seedaa oron the bts4E gjth#form 23.Site diagram or additional well details:
S.For Geops okDPT or Closed-Loop Geothermal Weiler having the same You may use the back of this page to provide additional well omstiuction info
const<ttction,C*1(3W 1 is-needed TadicAte TOTAL NUMBER of wells, (add'See Over'inRestaft Box).7ou may also attach addXmd pages if ne eastay.
dn1led. U.SOMITI'AL Il�ISTRUCTIONS
9.Total well depth below land surface: A) Submit this GW 1 within 30 da+s of well completion the folio
For muldpk we&L t all depth*d4 ftrew(aampk-3(poo and 2@100) " mp per wing:
24L For All Wells: Original form to Division of Water Rsaousoes (DWR).
10.Static water level below tap of eaadag: (ft.) information P ik Unit.16171KSC.Raleigh.NC 276WI617
JJ>Nater lezel tr uba:oas6e�'tae"+•
11.Borehole diameter. r (in•) 24b.For Injection Well=Copy tv DWR,Undagroimd Tnjecticn Ca*d(IUC)
LL Ptopmn,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:_ ST�►�— •'i' 24c.For Water Sup*and ODea-Lo y Geothermal Return Capyto the
(Le.�totasy,vW diteet puck etc.) county environmental h dtn aepa �m"me c ily where—'1
FOR WATER SiI M.Y WELLS ONLY: M For Water Weller produdaz ow INN GM;Copy tD.Dn C=A
Petmit�Progtats�ta�11 C, ei i76�99.1611
Ma.Yield(gpm� Method of Rose �'Y
13b.Disinfection type: 7 Amount: w
Fours OW-1' Nwdt Carolina Depmm=of Envft==l d QmUly•Division of Waxer Rescamo s Roviwd 64-2018