GW1-2022-01745_Well Construction - GW1_20220207

WELL CONSTRUCiTON RE!QQ V tGW I)I) For internal Use Duty: �,
L Well Contractor rmattoa: "
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5 3 5 aoo R' 30 0 R
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FROM TO DIADIETM 1 R5S MAaitTAT-
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2.Well ConsawdonPamit : IN.L A02A 63 5-` L �D: 'cnstrr�olrTQBING d;Qio:[ 1,-� :T• y�
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3.Weu Use(cheekwell use): _ R st io
Water Supply Well:
PROM TO bIAMt{l�t ST OlSOM -Tl MATntUL
OAgricsilttaal OMtmicipaVPublic R $ ia.
OGeothamel(Hea(ng/Coolmg Supply) den i Wata•Supply(single) ft.
I
❑Ihdust iaVCm=e:oiai ORmidential Water Supply(stinted)
9 •tm OWells> ,IS.°.GROVT•�.: .: :�'-i%+ t.' .»..�.i�. 'cSEi: '�f;s_:.:5?:��.<
100000GPD FROM TO: Mw7rm.4.L' ^r:MMAC 3irN=OD&"OVNr
Noa-Water SapplyweII: R
OMonitaring ORmovay R R
Injection Well: YYi.i1
R
OAgtaferRechup . MmundwaterRemediation
OAgmfer Stomp and Recovery DSalinity Barrier 'M�/GRAVBLPA d" • :`ry r�x�; ;"„rXACMM r-MZn �•t t:n.
Tb MA�terAL II1sprA�1@trMi189D
OAqui£er Tea OStomr ester Drainage :z tt
OFgaimenWTecbnoloSy ❑Subsidence Control R it
OGeodonal(Closed Loop) OTiaoer
=20.DBILLIl�IG•F�O�' atlitliaadioa�ii"sliiib'N" '_,• �.
OGeothamal(Heathrg/CoolkwRetum) 130d=(explain under#21 Rmdm) FROM TO assc�Rzplloxaele y,.v:.etxv CO-)
4.Date Well(a)Completed: -2—2 Z Well Mg R R
5s.Well Lolation: • R ft:
-'Dayc� �?i nniC� - R R ,_ .7
F-My//Qw—Neme F—IwIDOOti'qpb-me) R R O
7 zaps
M V, B Q m4 L.n R ft
P13YsierlAddress,Gay,mdTp �— R R •'r,,�pfa :�:; .'1,:�;'4g
C-MtY PeeeeltdeoaScerioallo(PIII) n
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
gvmn Sell,owe boom is soffit) 22.Certification:
32 31, 39 ' N , 96' 33' 1 4 .. W
/ •6 -g _ZZ
6.Is(are)the well(s): ce.e anent -or OTemporary 270' Sim° Date
pair to an ens �''����8�*1�I�bY�rharrbnrrJl(sJ,.m(irreJ eoanr�tdmac�{aoe,.ah
7•Isthisare existing •OYes or O 15A IMdC 02C.0100 or ISA ArAC01C.01WIM Can Srmdmrism,ddnroe,
Ifddsiso�rp �tIIoabrawnxeLcmnarocrloabg6rmmtonmidagd�rhenoaoxefrhe ofmfssww A-=beappvvtdrdgo the-iwmaOwn :
py
•�rp�voider€Jl�rniorls saLraa oro�r the boxkoflfrfs:/bror, - "� .
23.Site diagram or additional well details
S.For GeoprobrJDPr or Closed-Loop Geothermal Wells having the same You may use the back of this page to prat ide additional well con*uctioa info
won,only 1 GW 1 is•needed.Indic1te TOTAL NUI MER ofwelis. (add'Sea Ovee ill R=adm Box).You may also attach additional pages Ifnewssay
drilled
' 24.SUBMITTAL ItISTRUGTIOPiS
9.Total well depth below land surface: 3 1.5 ft
ForaadtlplsasIIrlfstaQdgJa�f��v,rni(esaarpte-3(a)200•m,d1(oji00� ( Submit this(;Wlwithin30daysof wen completion per the followbr
10.Static water level below top of easing: 6 (�) 24a. For All Wells: Original fora to Division of Water Resources
1f+w+urkea(tr ad,a�t oar6ig use"�+i boron Pmeessiag Uni4 l617 MTC.PAWgh.NC27699-1617
11.Borehole diameter. i9 Can) 24b.Foi Eatection Wells:COPY W DWR,Undagrtnmd 4emm Comma(IUC)
nq PrOprmn,1636 MSC,Raleigh,NC 27699-1636 •,
12.We*constriction method:-R o b Y i l
fLG,+� ,.caw .�) �' d°ae�- Got�hRetunWellscap,fothe
Cavrnenn ofthe
FOR WATER SUPPLY WELLS ONLY:
24d.For water wells 0 1 roduft over 1 0�M, GM.Copy to.DWR,CQWA
13a.Yield /0 D Pamit Pm9mm,1611 MSC,RWei C 2769�i11 It
-
(fP� Method of test: •�
13b.Disinfection type:,j�:jT Amount: 1 !j '
Form GW 1' Nor&Carolina Depum=ofEwi omarml Quality-Division of Waa:rResomoes Iteviud(r6.2018