GW1-2021-02742_Well Construction - GW1_20210810

WELL CONSTRUCTION RECO (GW 1) For btemal Use Only
L Well Contractor Information:
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WeIICootraetorNwoc FROM TO DESCRIPMN
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NCW49Camtis Ca6&atiapNntnba
1S..OUTERCASI G(S)e welb ORLIl�
V CAAJh'Yi,.J '9�. yr" FROM T9 D7AMEM. T MAlIItW,'
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2.WellCotntracdonPermit#: V� V W 'i�M)HI�iERCASQYt:oRTUBIIv cif
LLtratJ kwaQeorabv�tlenP T Cormry.Sur;vwforxot ere) + 1 R R 57 i3 1'i.
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3.Well Use(cheek well user R iZ is
Water Supply Wed5CEtSErI
❑AVicAhutai ❑Municipal/Pt be FROM& TO. D siuizSM I M&MUML
❑Geothermal(Heating/Cooling Sttpply) deatial Water Supply(smgte) R R Tm
olndustrial/Commemial ❑Residential Water Supply(shared) I$GRt7DT
-0lidgetion ❑Wells>100 000 GPD FROM To MATERIAL,. EK ACB►UNrMMOD&A OUNr
Non-Water Supply welt- fL Z R Z
DMMII" ❑Recovery it R
M;c-M Well: B2 rh ►A g2k a�
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❑Agai&r RwJwV ❑GmundvmW Remediation
❑Aquifer Storage and Recovery ❑Balmily Barrier ;19 SAN D/GItASEL PACE'd-.. R s, _ `,emirs•' `s r.-•,::�..
FROM TO MATMIAL vIIllpfACAI@il M!
❑Aquifer Test ❑Stormvrates Drainage .S R
DEMMdutudd Technology ❑Subsidence Control R R
(Closed gyp) ❑Tracer '20:-DRIId3N(;LAG ate sdditia®alsibati'if"" -
00wthemmal @ lmg Reuua) ❑Other(up4am under#21 Rema& FROM R v TODasc noN co,a .�aie.ec;: :ate
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4.Date Wells)Completed: 0 y'Ll Well ID# R R
r e J-J� S.-
sat.Wdl Lotation: - R fR
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Factlity/Ownr Name Facay p#(¢qvhc2we) R R
C c n EA'A- fZJ — o A Ill•, a-i R R
Plysical Add<ear,Cit1,and* R R
Cyr L Parcel Mandficaaon Na M
5L Latitude and longitude in degreeMminutestwonds or decimal degrees: (r$0
Cavell&Id,me hVIM is and) VA j 22.Certification: .�
6.Is(are)the well(s): rmanenL or ❑Temporary S>tMture ofCad&d:.WeMmracaoa Date
7.isihiaarepairtoaa well:- •t71'e4 or ByJIVz igdaFfmn 1hgreby- ryAVXherell(s)wm(werq)convosc daraaoondmm wah
eriafing `6Nlo 15ANCAC 02C:0100 or 15AMAC 02C.02001Pe11 Cps raegio a Smmbn&and turf a Copy
Ijardr it a rapotiffloai brows,va conamwon MfwWwon and ezplmh me,woa ofrl a of rhfs record has been pvvided to dx>veff ovner.
repotr aadar l21 ram ph seavon or on the hoceof rhtFfornc 23 Site diagram or additional well details: �
S.For GeoprobeMPT or Closed-Loop Geothermal WeOs having the same You may use the back of this page to,provide additional vwe11 Coesmsc6m in&
wilstiuuctien,a*1 GW 1 is needed.IndicAW TOTAL NUMBER of wells. (add'See Ovee in Remarks Bo)4 You may also attach additHmd pages if necessary.
drMed:
24.SUBMITTAL WSTRUCTIONS
9.Total well depth below land surface: /
For mrdtlpk neOs 6sr aU depJa 1f d (ez®,ple-3(a)200'm d2®1M ( � Submit this GW 1 within 30 days of wen completion per the following:
10.Static water level below top of eating: 60 24a. For All Wells: Original fora to Division of Water Resources (DWR),
Ifwarar ksal u above Casbe'sm"+- I ( ) Information Processing Unk 1617 MSC,Raleiab NC 27699-1617
1L Borehole diameter. {m) 24b.For Infection WeMc Copy to DWR,Underground Injection Control(NC)
L Program,1636 MSC,Raleigh,NC 27699-1636
IZ Welt construction method:- R V T A lvl —Ark- 24c.For Water Sn and O Loo Geothernal Return Wtd� to the 0-e,-wa;rotay,caw died pwk et:.) tal h Den- p Copy
envnartmentafhealth the county whave installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells rode'mg over 1 GPD:Copy to.DWR,CCPCUA
13a.Yldd(gl* Method of test Y' Permrt Program,Loll MSC, 1 H
13b.Disinfection type: Amount:
Fo=OW-1 North Carolina Department ofFavfivnmentel Quality-DiAwn of Water Resources Revised 6-6-2018