HomeMy WebLinkAboutGW1-2021-02748_Well Construction - GW1_20210527 I
aE,CONSTRUCTION RECQ (GW-n Forte Use only- �.
L Well Contractor Information: '
WcllCoaftlaw Name FROM TO DFSI�rPIION
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NC Wen ContrwtorCatifieationNamber 75.OUTERCA.4�tG ffoa'nmo wac1h OR TOM Of
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2.Well Construction Permit#:RW 1r�0 D D 73 L IWX To aIADMML 101nesTstrsi.'
rAv aftoppl)mble wvdl cmaftcdonpetrrtfu(le-WC Cozmy.se&vwww-ere) f fL ',S 7/F j b %h tCA-
3.well Use(check well use): R fL m
Water Supply Well:
FROM TO DIAMSIF.B • SLOTSEM ITHlr8 S3 MA18RtAL
OAgricalaual OMimi6paVPublic ft 4m
OGeodezml(Heab*CooW*Supply) 499dectial Water Supply(single) & in.
OlndustrwCommaaaal dResidential Water Supply(shared) 18.GROVr _
❑ on , OWells>1007MOGPD FROM TO MATERUL s�rwc��rrai"&"0TW
Non-Water Supply Wen fZ fL lVea r
OMotvtoring OReoovery fL
Injection well• —�� R
OAgnifler Recharge OGratmdwater Remediation
?19 SANDfi=&YZLPAO d
OAquifer Storage and Recovery OSalmity Barrier • FRDM 1.TO esATSRrAL n�racnaarr
OAquiSerTest .OStarmwaterDraioage fL R
0agedmenwTecimology ❑Subsidenot Cool fL fL
OGeotliemial(Closed Loop) OTm= =20 DRnJZ4G LONG.azm�atsbie
[IGw&emW(HeWng Coo Rd um) DOthes( under#21 Remarks) mom To A>sc�aox(auto a.ah.at - era)
ft. R.
4.Date Well(s)Completed: 5-4'ZJ Wen LD!# fL
98.Wen Location: s' iL RLUt I
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1 e K[ _ Ulf
faw7ity/Oamer Nana Facility EN(if apphcabla) fL MAY
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Physical City,sadZip R tL ^; QVVR 5t'L1l011
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64 Ob y e7G 3 2L:Ris1t3ABIl.S . _ ''' .
Cody Parcel Identification No.(W --
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcu Ewald,0-ladioug is sue) ' 22.Certification:
CIA
6.1s(are)the well(s): OQErmaMIt. or OTemporary Signaoae ofCertified'�JenCo o� Date
�_� a,'a+gm>Rtl�'.fornt 1 heir cern�'tict r1�e>raft(=)wow(+�> 3e aaam,dmra,vit
7.Is a b a repair to an easting well:- r wis or Lyll+fo ISA 1TGIC'02C:ajoc--or ISApcAc o2c moo i"iell c si o Swakmb wd ajar a cop
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Ifdds isa rear.fillota,bow wva commecdon mformeam andesplam me name ofdx of this reooid has been provided io the wrr11 owvra
reprnr coder 921 trmmas seed=or on the backoJdasfomi 23.Site diagram or additioaal well deph*.
8.For Geo be/DPT or Closed-Loop Geothermal Wells having the see You may use the bark of this page to provide additional wen constructm info
moo,a®ty 1 GW 1 is needed indicke TOTAL.NUMBER of wens. (add'See Over'in Remarim Box}You may also attach additional pages ife n oessary
dolled 24.SUBbIITTAL WTRUCTIONIS
LI9.Total well depth below land surface: 2 (�) Submit this GW L within 30 days of wen completion per the fellowing•.
For v-kpk-cgs bsr aft dVda•#1 (agile-3(a)200'and 2(aj100')
C, 24a. For An Wells: Original f= to Division of Water Resouroes (DWR',
10.Static water level below top of easing b ( ) won Prig Unit1617 MSC,Raleigh,NC 27699-1617
rwaro iinw u above aas5rg:rse"+/
1L Borehole diameter. v (m) 24b.For Injection Wells:Copy to DWL.Undergouad lnjection Control(NC
Pmgtam,1636 MSC,Raleigh,NC 27699-1636
12 Wen construction method: a - A �� — 24c.For Water Sandy and ' n-Loo Geothermal Retnr_a Wens:Copy to th
(ia--m tow,cable.&add A ere.) cormty envionmenW health deparftnent of the county where
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells urwodncint over 100.900 GPD:Copy to.DWR,CCPCUi
Permit Progam,1611 MSC,Rape igb,NC 27699-1611
13a.Yield(gpm) Method of ftsC G
13b.Disinfection type:-1H_ Amount
Form GW-1 Nadi Cwoba Dep mtnent of Euvitonmeatd Quebly-Dkvmon of Water Res== Revised 6-6 201