__20220311 (53)

•
WELL CON UCPION RECC GW-1l orIntsmal Use Only: \
L Well Contractor Information: - • L .
L • $ . f h e c G�"V _
Wen Coanaetorxame L PRAM TO D�IPaox'
• 3.5 3 s aooR 3GOR .
ft. R •
NC Well CowincroorCrtiScatioaNamxt •45.OMERCASING(foe a ati-cmiRtWells)ORLINER&•' ' ' ').t 3...•-. .
FROM TO MAME= 17ffiCffi'0.93 71(A�IAL
T AAAp„Y11M'i. e. f ;a.
Name L 116.DINER'CA.SRVGORTQ�IG(imthQmit _ l).1 aA.rF4.-t"..• . x •
2.well Conn uedon Permits: 35
Go
• FROM • TOE5AMir� Baas aaATIZISL
ItualT applicable well eaans cstnparn tcs(1.e.MC.Camay,S .Varian:4 a s) .4 1 R- I 0 ci R S7/6r m- 11•,t t.— p per
3.Weil UM(cheek well use): - R ft. in.
Water Supply Well: • /17=s RFV .. :.•.:0,•.;::;:1�.?xt:.,.= ,mow i? ::i';yta. sw„_~
PROM TO DIAMSrRR scars z Tl MATWAL
DAgriculhnal fah tmicipallP:blic R R ie.
•
OGeathennal(Heating/Cooling Stgrply) d al Water Supply(fie) R ft i -m, .
OlndusniaUC� onlcounacf 1 DResidendal Water 5upp1 r(hared) -IL . .:..;,_:v.. .
9laigntion • 3k. OWelis>100,000 GPD • PROM TO `I�MAZffit AL r runt, xr,�oamimaomrr
Non-Water Supply Well: D .R 23 R! Neat /V I i v'?4 •
• S • ORecovery ft. ft.
Injection Well: FP I'ilAA - P whir 4./
• ft. ft. '
OAgmdaRecharge ❑CsntmdwaLecRsn:eedia6on •i19.SAND/GRAVSLPAc2r6fi •'20-:`ar= :.c: ta:'rrtvzir�•
CAgmfer Storage and Recovery nSaimmity Barrier • PROM TO MATERIAL IMPIACMONT RIZO
OAquifeiTest .0StormwaterDrainage .ft • ft. .
• OPxperimeoealTechnology . ❑Subsidence Control ft. R •
DGeothermal(Closed loop) ❑Tracer =20:•DHIIdAVGIAG{attiehiddideml 'R•i t) ,V: .a.' == '.•'
OGeotbesmal(Eeatmg/CoolingRedan) ❑Other(emlaia under#21Remarks) PROM TO asscR>prrox( ��.o,,.vnacvs.,sat.i�,erei
R R
4.Date Wells)Completed: 3-7 Z z well ID,i# R $
. Se.Well Location: ' ' ft. ft
R R
'AAteh2 e1 W-eeices - ft. —
• Faalisy/OwmcName Peaty lD6(ifappl+mh r) ,
` L�n ft. ft.l I�o�l� Dl1- MAR 1 2029
A1\451
1_A_/•r Fact]IIdeatf_aca�i No.(PIN) .. . .,
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(Ewen field,09G SODS is sue) •' 22.Certification:
35' Ali' Its ' el go ' 5' • 58 ' w ,7 •
6 are the well(s): QPermsaent :or / Sigaatae. ._•...-. .el1 '':—•.• , . . at l t
Is(are) �() ❑Temporary ,^�
�vl d By signtrigda*fo l ncrteewrll{.$),.m(were)eo,soractedttac+o C,wtrr,
7.Is this a repair to an ens' welt.- 'ClYe s s or -E (o ISAIVCAC 02C:0100 or ISANC 4C 02C.0200Well Cptaaactfon Sarnerc s unit ere copy
Ijtkb'Isatg+err,�osabmws well crraotacQotaferarm and cscicbs the,maaeofthe efd*nemvdhasaeasp av1dedmrliewet own=„u _ ._._—,
tspn&loafer Z21 rsatmisse:tratt orott the back aftJasfornr 23.Site diagram or add onal well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to protide additional well construction info
• construction,only 1 GW-1 is•needed.ludicate TOTAL NUMBER ofwells (add'See Over'iIi&Marks Box).You may also attach additional pages if necessary.
drilled: 24.SQBMITTAL INSTRUGIIONS
9.Total cacti depth below land surface: 3 ' (ft.) Submit this GW-1 within 30 daysof well completionthe following:
Par nadeplewels Bs:aIIdepthfi ery:(ea�ple-4200'mt144100') mP per
10.Static water level below top of easing: I OD (n) 24a. For All Wax Original form to Division of Water Resources(DWR),
'water knits theme „+. Information Processing Unit,1617 MSC.Raleigh,NC27699-16I7
11.Borehole diameter: l9,ii {m.) 24b.For Infection Weak Copy to enDWR,Underground Inject Cool(IU C)
Frogman,1636 MSC,Raleigh,NC 27699-1636 ..
12.Well construction method: /R D awl ' A " 24c.For Water Supply and Open-Loop Geothermal Return Wenn Copy to the
(i.e.alga,may,rabk,direct peak=.) • .. county environmental health department of the county where installed
• FOR WATER /�SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 10�00 GPD:Copy fo,DWR,CCPCETA
13a.Yield(Epp O Y' Method of test: ('1 t ►^ • PetmitProms'1611 MSC,Raleig6,NC 21699-1611
13b.Disiuf ctioa type: r)N Amount: I Z 'v
Form GW-1' 0 North Carolina Depanmrot ofFmvaonematal Quality-Division of Waa:rResour es Revised6-6-2018