GW1-2022-01764_Well Construction - GW1_20220215

.f r,U CONSTRUCTION REGQ rGW 1) For Intemal iJse nary:
1.well Contractor Information:
14.WA3'LR7,OM.... --•y
WcIl CaatmcaorName - _ r xaoM Zn DFSCSIPiiox'
N Weli Ca ftwtw Cefficgfiaa FEB 1 ���� !R� /�1f 1Ufa
O..J�aC 11L{G ua[: medtirm VBTII�R rF.^Y.... ..
177 nresgraa .. ���,
CampawNeme R $ m.
2.wen Co ilA (ASQ4GORTU87NG ""d .:l �i!" rr..,•.
mtractioa Permit tt: runner .�
I1sraII a�pdecble�.eAeaao-ac7lnnParm►u(Le.WC Comay,s-A Yosi 204 dr-) �,' {� 5brennCrra in l�aQot� nsAr>asret :•
3.Well Use(cheek wen use): _ ID
Water Supply WeR• I.a 7.=SQtBtt;N'a. -•+�:?.'ks';�i�'•`:`•.yy,ax.,:,-�i;:v�+�,��:'1�L=,.".:�.'y.%2:-:1�'i,�^'.a'X'.✓.
❑ � ❑M M To D1ADO;r1� SZOiSfia MATXRTAL
crpal/Public R & in.
❑GeotheayC(T3ca rch1l olmg SrrpplY) Water Supply(15000 it. 8 Ter.
❑7ndusttial/Commett iat Resrdmtial Water SupntY(shared)
fl "on ,Ia.`.GROIII'•t•� ;. ;.:'•-:,p•;:` .."••'_:;•it..".:�=:�:.!�J_w��:F„<
❑WeUs>IM 000 GPD M To rMAIRMAI. t tc r aD .sn[auxt Non-water Supply Well: ,: t
�°ao� ❑Recovery
Injectlon well: R r
CAquffirReabargeDGVoumdwatrrRemadMon
DAgmfer Storage and Recovery ❑SaiiasyBarrie[ ROM 1GRAVSI;P9 d " :`;rs M3: `�^'�t'
-MATERIAL II1spFACflltalr11�9D
❑AquifrrTest .DStamtwaterDrainage $ ft
❑Bcpo*uootdTechnology ❑SubsidenceContol g
❑Ca1(Closed LOOP) DTractr 20:DHILLINGF attieL`a8ditianiisbri 'R' OEM
❑G sl(Eearmg/('-oelinSRdtlm) DOther(explaiaunder#21Remarls) moM TO DsscamlYONtaga y,uv,.et � '
4.Date Wells)Completed: Well M9 tL !C
51-Well Lotation: ' it ft.
•S�G�G l li 6 ����� - � R
Faai}uy/Owner-mere F-MWIDO(ifapplicaMe) & tt
i
fz
11�.cal/Ad,A&.%C,*y m,J4 T— R R
V V.(,/�(,� :ZL:REMARBS•,. �. •.. .,.w.�.::,r ti��:,,
County Paeeelldeac5catioallo(Plld)
Sb.Latitude and longitude in degreeshnihates/seconds or decimal degrees:
arwen Sell,erne ku/loagis sue) ,
31 C/ f ' 27.Certification:
ti.Is(are)the weIl(s): =f=t�4r DTemgorary 2 0' Sigaanae ofCartifie&WellcoutraclorDie
7.Is this a regale to sa By�s+ 8 *1 IherrbY thor the wr.a($was(were]eornvrraedbraeooe+dmioewtrh
castingwell: ❑YG or'6N. ISANCACO2C.01000rISAlCdCO2C.0200FellCgaaavebn midTheeaco
py
ljddr b a rrpmlt JtII osabrowa hell cn�aa+aaon 6 formeafw+md ezplc6i Jre rmvo:ofrhe af�ir nncmdhar bone provided m the�reII menu'�ro�dsrtrll tmrmtssa�ott neon the barkofflRsfarm. -.
23.Sift diagram or additional well details:
S.For Geops obe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to proVide additional well construcdon info
eanshuctioa,anly 1 GW 1 is•needed.l6&01te TOTAL NUMBER ofwells (add'See Over in Reniarlcs Box).You mey also attach additional pages ifnec mmy.
dared:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Q •
Formal Awe&Ho aad9da tfo9�'r m(e�rple-3(o)200•m d2(�(0� Submit this GW-1 within 30 days of well completion per the fallowbsg:
10.Static water keel blow top of easing: 6 O ft 24a. For All Wells: Original Jbtm to Division of Water Resources (DWR).
Ifr+at�JevdlsaSoNeC°�+CWe +- ( ) bforuadouProcessingUnit,1617MSC,Raleigh,NC27699-1617
l� 24b.Foi Infectio to DWX IL Borehole diameter: n Wax Cru.) PmF,ram,1636 MSC,Raley NC 2769636 ��j �C )
12.WeIF tonstraetion method:__ a h-1 7Ac.For water sapDly and Geothermal Return WeII�SuM rotary,cable,daectpmh,ere.) Copy to the
:. sty envu0nmental health departm=ofthe county'Tmcftned
FOR WATER SUPPLY WELLS ONLY:
24d.For water wells produft
over 1�Cry tO.DWA CCYCIIA
13a.Yidd(gpM D Method of tort: ►'z`
Pam!110 111 MSC,RWei C 9 11
13b.Disinfection type: Amount: ' -2i L/
Fame Gw 1' North C h=Department ofFaiavr>mml Quality-Division of Wsa r Resoraaes ( Revised 6.6-20I9