GW1--03412_Well Construction - GW1_20230515

WELT,CONSTRIICTIO RECO —`
GW 1 For Iateznal Use Only.
Well Name MS
FROM TO DES or?
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2.Well Construction permit#• / (� if.IlVNERCASDVGORTUBIN therm aldaled4oc
TO
Lief affappUeabb well censotralon pamrtr(La M;Cot&%Sale,Ya"aneq ele) FRO-t-M DrAM zffiCafEss is rr>RrAt
3.Well Use(checicwell use): ft g is
Water Supply WeIL- 7.SCREEN
❑Agricultural ❑ FROM To 11) �' Iv�mdicipaUPublic tt tt DID
E
❑Geothermal(Seatiag/CoolingSupP1Y _ m
ential Water tsa�ss nfAs rAL
❑lndushWCornmetcial �•'
❑Residenhal'Watea Supply(shared) GROAT
AT
❑� ° ❑Wells>100 000 GPI FROM TO
Noa--Water Supply Well: M►TmwL Fa�1,01, ErnMeaoD&AMouNr
❑Monitoring 3 ft
K
Injection Well: ❑Recov er. � 42 ft
❑AquiferRecbarg .. ft fe
• eO�C,raBadwaterRemediatioa .
❑Aquifer Stomp and Recovery fp 1 '• 19.SAND/GRAVELPACK d a liable
❑AquiferTest MAY❑ tom Cwate;l e , FROM To MATEItrAL EII�LACAVIINra�TaOn
❑FxperimentalTechnology s• ► �l8 es"'�or�rol
ft
❑Geothermal(Closed Loop) Jvw'� tr' —'A
❑Geothermal($eatjpg/CoolingRetum) ❑Other( lain under#21Remadss) 20.DRII.LIIVGLOG attaehadditio%Wsheebifneeas
PROM TO DES-C MON(.1. hardo =Wnek a - sin,ere
ft.
4.Date Well(s)Completed: Well ID# ft $
Sa. SULocation: ft. ft
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• Fa 'ty/O+merName es
FaalitYIDt€(�faPPliable) ft vDy, V'
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P Gay,aadTp Wo--4rtJl� & -
• 2LREMA.RKS!
COS Parca ldeotific ationNa(PIIQ
5b.Latitude
and longitude in degreedminutWseconds or decimal degrees:
(iNell field.
on .
g s(su�tliamt)
r ` � •N�� • l .. � 3 , 2ZC
W Per D v
G.Is(are)the weII(s): permanent• or ❑Temporary. (}/ Si 6f o 3
• ` Dato
7.Is this a repair toanexistingwelL. ❑Yes or 0 BYsfgnfngth Ahkrherebyca*,hWfhcveU(s)way 6rere)cOmvuacdfnoeeordencewith
Iflhlr frorgwfr fiff=alo m wffl cOM&A alon ormadon and esp f ohs rceordhas been pvS:l dto th 02C.0200 Well Coruonedon Stmidardr and!lint a copy
rrpairrmder#21rrmon6•reedonoronthebackoftVrjorm enotrveo the 1 prwldedlorheweIIowner.
23.Site diagram or additional well detar7r-
S.For Geoprobe/DPT or Qosed-Loop(Geothermal Wells havingtbe same You may use the back of this page to provide additional Well construction info
drill construction,only i GW i is needed Indicate TOTAL NUMBI�i of Wells (add'See Over'in R emarlts B0x)•Youmay also attach additional pages ifaecessary.
drrllcd
9.Total well depth below land surface: Z_Zo 24•SIIBMITTAL�STRUG'I'IONS '
FormrrhlpleweQr/irr all depthrld/BuenlI—aPle-7W000•arrd2©100� (ft) Submit this GWi within 30 days ofwell completion per the following.
10.Static water Level below top of casing. LO • .(K) 24a:For A11 .;; Original form to Division of Water Resources (D
Ifwara level is above earr +- ` Infom�ationProeessing Uait,1617 MSC,Raleigh,NC 27699-1617 )
11.Borehole diameter. 24b.For Inieetion We1Ls:Co '
Pmtp-am,1636 MS Rid Pr to DWI,Underground Injection Control(IUC)
12.Welt construction method: b Q gb,NC 27699-1636
(Le.PMretaxy.cable.direetpmb.etO 24e.For Water Suup�and Ooen-Loon Copyto the
FOR WATER SUPPLY O0�'eatruanmenhl health deparnumt of the county where installed
WELLS ONLY:
� ) /( p Bo�roWater Wells rodncia over 100 000 GPD:Copy to DWIt.CCpCUA
13a.Yield m U Method of test b'r'�,1 11 MSC,Raleigb,NC 27699-1 11
• _ tt
13b.Disinfection type: Amount
Form GW-] '
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