GW1-2021-02795_Well Construction - GW1_20211103

CONS17tU O RE -1 For Internal Use 4Tb L-
1.well Contractor Information: �`•
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Well Coaaawor Name r 1 I ..a J '—' FROM TD ON
NC wen Cem 640r Cadfieati=Namber prooe, R R
f I�iotr'p�NR$e`i'0n ]S OUTERCAS�rG mil-e,;aa:rem oaln�R
k .l)lflfl'31AnN. FROM ?O D 7ffiCffiYLS9 17it16L
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3..5 5 iiG cAstrrd;OR �.:.,•.,
2.Well Construction Permit S:_ F1tOM TO DTeM:rralt iTD)CT� ✓
Lin aAappHmble waAaerorrrclan pera�rs/ic ZAC Cm*.Srera.Ymim.c�ae) �, R R / hL t C .YL. ,
s.Well Use(cheek wen use): R, f
Water Supply wea '.. ;r�Y,..ram, •tw'ab', ., ,t..y�,r M.
O`°'Vicultural ❑Mueicipal/Public MR TO D SLOTSrLE rtsTneul.
oe>eoffiermal(Hespwwcooung Supply) —tMidential Water Supply(single)
°lndustrialleommeroiat tL
Rchrigatiopesidential water Supply(shared)
Noe-Water 100000 QPD Ow
r snp�q wen: O R :
fi
t]Monitarrng ❑Recovery fL QAt'
Injection Welh -
OAquiferRachap ❑QroundwaterRem&Uation R
orage !Gt£tAVSLYA��St �Reco�Y ❑SaliaityBarrier •i19 SA1VD d'•" r^�I;�•�;� �, w,, . :.,,,,,,v
❑Aquifer Test TO
❑Soormwater Drainage
FROM $ S McTEarAt, ,t >a►mtecat�rr
❑ Technology ❑Subsidence Control M tL
OQeot>xtmal(Closed Loop) ❑Tracer, ' `DRII.LIIdG LOG
❑Qeothetmah *ling Return ❑Other vader#21 Ramadm F80M
4.Date well(a)Completed: 16.11 2 Wd!II?It g tL
Sa.Wen Lotation: !z
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F� Name Faatiry IDJ!(ifaPP}ua�ble) R• , tL
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!'deal City,andzV
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' �11d�8rxdoallo.(PII.i) ••�•.:
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�field orm�kofts is �tes/minetes/seconds or decimal degrees:
22.Certification:
N. �'�56,• _w ;
6 Is(are)the wen(s): ermanent -or ❑Temporary �7to� Sigeenae of
/
7.Is this a repair to an eldstiag wen;, ' t�N t , Date
FPWid #21, sa.t�„y,r.err tkor a o �MAC��� .�rr�rr�e,�r�:)„�,h�j�,�n,
a'da lJr,emar�Sw rm open o f�Q1 m d 1R�QDr �*off& qf*s , has hem oM NC4C O2 C.020OW U
SmctmKr and dw c ally
8-For GeopTobeMPr or Cl sed.Loo "°
p Geothermal Wells 23.Site diag,.am or addttlonal wen details:
o"C6 CY I Owl.]is•neede& Indtcdte TOTAL the same You may use the back of this p�to provide additional .
NNi�ER ofwells (add'See Qvet is Reteadc�Box),You may also aimeh R8 �
9.Told well depth bdow land 5 Zo t 24.SUBMITTAL INSTRUCTIONS may.
Fornarldple waIIrilsr4a&P hr il�Fierrr e�
��-��oo•masg1oo7 (�� Submit
10.Static"ter level this GW 1 within 30 days of wen co
fe u below top of seeing:,�� �` rnpktlon per the fonowIn,
&tits�/I+• (�) 24a. For Wdls: or,OW form 11.Borehole dfamekr. b l Ong Unit 1617MSkbriwai to Dirwon of W, Rasotaees (DAn
�p 40n•) 24bk.Foi Intectioa W C'� 'NC 27699-1617
12 Well eoonme p?+b.eoc) a►•y -� 'dix COPY to DwR,U
1636 MSC,Rai n and k
. n�• �°$mR3, eigh,NC 27699-1636
�, l�on Cool(JUC)
24c.For Water So and 0 24,00
FOR WATER SUPPLY WELLS ONLY: C01 ell m epazim� stem
COPY to tk
13a.Yield(gp� 24d.For Water WO �f
Method of tesC r r permit 1 11 over 1 ME Copy to,DWX CCPCUA
13h.D�tlott type: .�• �, C,• et 11
Amount: r
Form
N°ort CaroCirta Depubm of Rnvi,=.,W Q--11Y-hoc of WaterResotases