GW1-2021-02773_Well Construction - GW1_20210923

WELL CONSTRUCTION REM lGW_I) For Internal Use Only: �-
L Well Contractor Information: "
L. S- �� � h E' a ta.•� - is wATERZON&S . - .
wen CmCaaarNme FROM To DESCRIFMN
3 '5 au $ 300 $
ft. R
NC well Cain CatiSr tioa Nmber
15 01TtEHCA=G tlorsa6lii.eas` *e% l)RLR�t
To DIAb EM u�tssr�r
$ $ is
�YN� -
;36.3lVNER'CASQIGOR TU7t1SVG •"'elrQioit -ei='::•i,:=rf`�:; ::':::
2.Well Construction Permit :_�0 ZI O,� I D U FROM I To Dism[m I Tex3mm IsasTanrer,
Ltsraftappdcobk wll aaruvaetleaP �f+�tAG Cororry Sage Ymiarre etcJ $ $ 5 7 in [
3.Well Use(check well use):
Water Supply Wed
PROM TO +;DZAMrna 1ffiG2mw 1MA3mWL
DAVicultuad QMlmicipal/Public t'e. R in.
0Geothemsai(Heatittg/Co jmg Supply) Aeatisl Water Supply(smgle) R $ ia.
Olndustrial/Commerciai EbResidential Water Supply(shared) 18/r'1tOIJl
fl ❑Wells>100000 GPD FROM TO MATERIAL MMMAC1flN1i8i ?AMZODd:AMOUN
Non-Water Supply well: % $ a I' AA ;
-44
aM s Dltwovery $ $
Injection Well: I C
DAquiferRedwye DGroundwaterRemediation iL R
OAgmSrr Storage and Recovery pShyBatrrer FROM
TO neAMur. _ r_•:aan:,...sia.�i. �:""•.
II1lZFAC81lT�i!'Ds?tT8@D
OAquifarTest OStoim oterDrainage $ R
ODgerimental Technology ❑Subsidence Control $ R
OCkoftmnal(Closed loop) 07racer ?20zDBILTaiG Ll aaaeLiBditmast Z Z;
aIv ~ `ma's:.• ':..,_. ems:
❑Geotixsmel(Seatng/CoolmgReuFm) O tn
Otber(a�lamut�er#21Reatim) FROM TO
$
4.Date well(s)Completed: •2U-L wenmlt $ ti:
Ss.Wen Location: $ $
c L $ R
FaerlitylOrvnir Name Facay M#CifapphwNe) $ , $ 2021
F*siWAd&-%City,sodZsp U R $ ` iPi ur aI ii r '
Lk
C—W Pmcel kkndficadon Nm MN)
Sb.Latitude and longitude in degre eslminutes/seconds or decimal degrees
Crfvmn Said'ow hd1m is sue) ' 22.Certification:
6.Is(are)the wen(s): Permanent or OTemporary ' l oo t s*Nwe of erti5ed_ c3lC nmcwr Date
By epzoe d9ifim Ih0ebycer001%atA.-weQ{rJ was 6sere)awaauaedatacomdm+aewerh
7•Is ibis a repair to an existing well' •ClXis or (INo ISANCAC 02C:0100 or ISAJVCAC 02C.0200 Weft Cwmhxffm Stmsdmds and dw a copy
4,d*&a npmb,,Jwotebm m well emancoast bg6rmmon and esplmin the name ofrlx of this recordhas bapsptoviatrd to the wed owner.
rope soxkr#21?awls secaron or on the back oftft fo of 23 Site diagram or additional wen details:
8.For GeoptokMPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additiooal wen construction info
constrrootim a*1 GW 1 is needed. Indidte TOTAL NUMBER of wells, (add'See Over'm Remarks Box}You nay also attach additional pages if necessety.
dried
24.SUBMITTAL
9.Total well depth below land surface:
3 Zo ' INSiRUCTiOP1S
For aar!>tple we11s ftst aft deprht#&ffV9W lcosrpte.3@200•and 2@1M ( �. Submit this GW 1 within M days of well completion per the following.
10.Static water level below bop of cubW. D (R) 24o. For All Wells: Origiaal fours to DivWon of Water Rasataoes.(D%n
!f waM,1evsl is above �cse/'+1 l/ Information Ptocessiag Unit, MSc;Ralaiglt,NC 27699-1617
11.Borehole diameter. G b {m) 24b.For Injection Wells:Copy to DWR,Undergoimd Injection Carol(1VC7
Pr
^ ogram,1636 MSC,Raleigb,NC 27699-1636
12.Wen construction method:T 6 T1 3 h, _ /—k+ �'
Cie,saga;sotuy,caw d'aea ru,etc.) { 24c.For Hates Sun and Otxn-Loon Geothermal Retaus Wen&Copy to the
Muoty envxronmemat halm aelmtment o2 ft cotmty where —wed
FOR WATER SUPPLY WELLS ONLY: 24d.For water Wells gMtcmff over 1 GPD:Copy to.DWR,CCPCUA
13a.Yield(gpm) Z Method of test: •'Y` r==Progam,1611 MSC, 1611
13b.Disinfection type:
Amount: �„��1�✓
Four GW-1 Nadi Carolina DVatm=ofBxMonmemal Quality-Division of Water Rns== Revised 6-6-2013