GW1-2022-01768_Well Construction - GW1_20220222

FELL eONSTRtTCTIOx REca` ((GG'w I) For. Use Only: �^
L Wen Contmctar Tmformattoa: -
W /'i I-P �/ �l J _ .114.WATERZo1�S• DysccsiPuox'
`E'� l�0 0�
NCWeUC=iD9=CeN� it IL
LCOIIiESCA_S$IG£�i�}p`rasedweIIa OBIaffii' .rT._•_.
FRDM DIdD� 71fd7Za7AL
i�p�yName - ,1 R R m
Well Consfroctionpamhg- Q $ $ S. +ita n�nvstz'UsstrrrGORTQB1t7G " s6ermit &'�:,,•.
zo
r an �a Yari-4 9M) -f-/ R G S7/y
r w
3.Well Use(eheckwen me). _ $ R ;a c
Water SR431Y Well:
DAgricahmal ieotfidmuFROM TO DTdMSrSR MO?SM ~ M IMUL-
OMMiccaUPubLc R R hL
Obdnst aV ( mar, Cooling SAY) ai Water Supply(fie) ft R is
- DladusnmV[`••TT�tAt DResrdeaaal Wetrt'Supply(sbamd) '
t7 'aa OWe17s>100000GPD -1�GRt7VS•��:• ,,�;:: :;r•. - =-..;;.i�_'.�;=�'_�t�..::::•-•<a.:
No�WatrJ-SapplyWeII: L' i :.xKPLwaM3trrP=moD&AMoIv r
Dbianimring ORecovery AllI r njection Weil: R $
r44..,dA
C OGmtmdwaterPemediedon $ R .
OAgmfrsStonyandRaavesy OSdiaftyBaW r iI9 SA2ID1QtA�LPJ► REMO`ar k:,: �f•�a + ;�E':%�
FROM 2�D MATER AL ^II4�FA�irMtJ89D
OAgniferTest .(3StozmwaterDraimge R R
OFxpaimarIIslTeehaology ❑SnbsideaceControl fi R
OOkO&=maI(Closed Loop) OTra= -21.`DEILL G•IAL' atbeiia8di ais 'if"" ,.
votbe>malMea&gCWjkMRtarm) ❑O&M(mlaiaueda•#E21Remaft) FROM ro
❑ D lsox otA y,.v„ac `ee
4.Date WeIi(s)Completed: e1-1'�•2 L WeD D)# R
ti
52.Well Lotxfion: & ft
ft R
Faality/OwoetN�e Fw7ayID#(ifapp5able) fL R ,
•••ppp{�{+{+,��VVV�..���.��L��1�V\►112 2 V�-e.c(t p( -� � �j q'"1O R R - -
/ y iiY
Y PmeelldonNo.
Sb.Latitgde and longitude is deg ees/mmates/sewnds or decimal degrees:
(n<weu field.one Ldloaga seat) �
22.Cert ention:
6.Is(are)the weIl(s): ermaaeat 'ror OTemporary I a sip ofCeeafied OVeIl l3 2-7
n�
7.I's this a re � ISA2�+8�*J�Ilrereby�yrinrrhenrll(sJvar(SrrieJ eoraaremdmanmvriaonaYh
paatDaaeristlnSwell:' Oyes or o ISA1VC�iCO2C:0100orLUJCACO2C.02007 effCpzftcmwawzivtb vid l�rampy
IjaTdrisasap�r,�t7arebrorai.dlamtm+eertaaLJ6rmmtmimdespia�thei�aoeafthe efthitrtm�dh�bmiprovldrdmSiex�mnio_
'Jrpobtarler�ll rraJmfsscroaormrllJebaekoffiarforni - •�
23.Site&Rgr:m or additional well details:
S.For Geop;obe/DPT or closed Loop Geothermal Wells having the same You may use the bade of this page to prude additional wdl aonshucd=iafo
oaasftctioa,tmly 1 GW-1 is needed.idicift TOTAL NUMBER ofwells (add'See Over'id Rem Boxj You may also attach additional pages if==uy.
d,Med:
24.SUBMTITAL DMRUCTIONS .
9.Total well depthbelow Indsaltw&- 6'a6 f
ForradrrplsW&AutaffdePhredt,Va„a(an qp @Z te_3@200'mid2pp1) (ft� submit thisGW-I within 30 days ofweII completion per the following:
10.Static water lend below fop of ens mg: G 0 24a. For All Wells:
A) Otigmal form to Division of Waft Resov m (DWR).-
11++, le�atsra3oHecri»�;ac//�+-I (/ ht£Om�iionPsw=iogUnk 1617M5C.Raleigi6NC27699-1617
11.Borehole diameter, l� 7l {m,) 24b.Foi Injection Went Copy to DWR.Lindagrotmd Need Caohd(I[JC)
PmFd a,1636 MSC Raleigh NC 27699-1636
12.Wen contraction method:
a 1\o�YL� —/i�✓' �
(L iota �'k p?'h•`a`) 24c.For pp and".. ==Ly cnVM menfafh�th Oepartmart Cmd3r Geothermal R ��'etunWella btu the
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells coda ' t over IOOM GPD:Copy to.DWR,CCPCIJA
13a.Yield(Zpn� 1 Method of test: Petmzt R'D�1611 MSC,RWei C 9 11
13b Disinfection type: 'f Amount: L+ w
Farm GW 1' lime CMa=Depa==ofr=&o==mI QwIly-Division of Wsa rptes oes Reviwa 6-6-2018