GW1-2022-05416_Well Construction - GW1_20220311

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WELL eONSMUCTION gEM t, GW 1) For lntmnal
L Well Contractor Information: -
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Water Supply wen:
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4.Date Welts)Compbeted: Z L WeD ID# $ R
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5b.Latitude and lov4 Made in degrees/minutWseconds or dechnal degrw:
(�'weIl field,one}at/loaga soffidcat} ZZ.Certifrea8o
3L' �3' �l• N 8r �2� 3q' w "" 2,9,2L
6 Nam)the wws): OFermanent •or ❑Temporary S*M-ofCaidisdtil/eIl� ' Dam
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7.Is this a repair to an eastLtg weir,- •Cl3Ces or rC11�Io 5AhrAC��Oa 1VCACO2C.0 dw 2W Wed Cown ego Sbvxb M r a zd dw a oopy
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n�ab�ader 11r,emmEsmaronoronrheberkcfrtarf 23.Sie dagram oraddWond well details:
&For Geopt obeMPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional viell cookuctiem ml
coashurxion,only 1 GW 1 is•nea3ed. 7adic ke TOTAL NUMBER ofweDs (add'See Ovee mR=mks Bcxj You may also attach additional pages if necemy.
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24.SUMMIAL INSTRUCTIONS
9.Total well depth below land stnfa- 1 (� Submit this GW:1 within 30 days of well completion per the followbag:
ForaadtlpfewsQtlicaQdefxhs+fdi�(t�rP1e_3(o}200'mid?@Ipp') ,
10.Static water kvd bdow top of easing: (ft) 24s. For All Webs: Or gmd fours to Division of Water Resoiaees(D An
hft�zdcnPmoessmgUnkl617M5C,Raleigh,NC276WI617
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1L Borehole diameter: l9 (1 0 ,Cm,) 24b.Foi Yaiectisa Weil=COPY to DWR,UadeM ound In w&a Cmed(Op
RoFdm3,1636 MSC,Raleigh,NC 27699-1636 ..
12.WeR coustraction method: D W- 24c.For Water Supply and Ones-Loon Geothermal Return Wells CapY to the
FOR WATER SUPPLY WELLS ONLY: 248.For Water Wells pro4=. over 1� M.COW to.DWI,CCYCilA
13a.Yield pe 1 MSC,Md C ! 1 11
(Pptn) 3 Method of test
13b.DisaIftedon type: Amount: Z 'y
Fora GW 1' 14ottfi Carolina Depmtmmt ofFavaoameoral Quality.Div=of WamrR=o=es Revised 6.6?A19