GW1--03846_Well Construction - GW1_20230609

o...' DiS' 'Y��3 TQN ME.,.Q �.,1.., rPor Itaternal Use Only: �.. .� _—.
1.Wan C orr don: L.... y� �a..__.w� ..,.�.......�9
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e C oatraactnr 1Vanans $et�aiar T q_q +1 35.C✓. w o
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NC Well Coatractat.Offlifizatian 11.1EmlXxe' Ilr: it, it C_e4 4I..4; or 10 .,.T
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"'2.w Ca n Permit ail.�" _ ..,..._ °Mte _ Mt: zl MAT i1 _ _ .
LOt Ell applicable eeroi1consrru^t'anpennits(Le.UK:,County,State.Variance,art.) ft, ft '1°
3.° •„ Use(aback wen ilea)t .ft. ft. .__ .l_.o_ `.__
FROM To— lBiAM[�ST ®Li,d'fuawr}1aS:FL'+i8'$4` 14ltT.
tictlltural • 0Mtmicipri/Public N, • 4t. I12.
❑ al(lleatinrlCcoling Supply) DResiriaariai Water Supply(single) l ti. --- -t. 4 la, ---�- _ _ _ _.___.__
Uindtrstral/C onarsaercial DRotidential Water Supply(shared) ,, M, ti^y — _.. —, 1 .. .. {
❑a ala _�?�71eX s top GPP ! now _ To__ xua ¢ _ �utatst�am t a P �s �dTLtaiT
Non-Water Copy WIT— 1. It a
C Moni ita OReeavery �it. ft.
r afar Recharge .._ _� CC4rcwn.3vrratr1 cmtadiatirm s ___ l _ _ - w - 1
CJAq.lifer Storage anti Recovery ❑Srlinity Burlier FROM TO MATERIAL — EtataT.c:tt x'R9.'S;'V13;S1Sr
DAayuiftrt Teat C]Sfarxnvtater Drainage
DEvatimental Technology CISubsidence Cont l Ft' 1 ft. _
JC1 1ntd(Closed Loop) Gnawer G LI mtti---rk r,
C]ts+ Qlsertr tii i ti>z�, rill lLe#ttrrt� ClCstlt;x{ems acplttin under21 fit FROM TO l ESC f�llol�a taaksks,Derr a f, jti_-: -
4,Bete W• ;a)Completed::s ::. Wen Fib i ft. ft." __�__. 7 '�'.""' ."' ., _
So.w Lowden: dti, rt.- e `�.P�' _ •;�
gasis. . ,et/0. 4 dam. _ _ __ _ - —_.-__..lL' L.....L.FL 3-•--
Facility/Qv/ace Nam Facility 1:13#(if opplizable)
Pbyat 1. .,C ,sad ZipB`' 'z'
County Race lbw$Gerion No.(PiN) -I
31u.Latitude endlrtutgttetake 1u dr„aresuJmt aeatttaluzarie©r decimaltl +Bette: L---._� ____ __� ____
(dwelt @held,ono latilong is saflie ) 22.r,ordneaton: Q,ry ,i
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Tel �7 ` t� .1.e' gl-- f F L
6.Ea( )t vntij�:,,. e t or DT's apot'itr^y lylrmturt of Certified 4Wt11 Cu ztrslatar
ay sjgring•thLc fors::,I hoety t:xraie that`the walla)1013(were)canserneted in aruardar n lath
7,Is this a repair to an,ezfelmg ta'NEI: DYes or ,4 o IA NCAC 0iC.01ttD or 154 NC.4C Ole.021.10 Weil Canstrucaan Steasdards anal that a c-opj,
(FALI Is a molar.Jill out kanuf wail corcrrruciton tmji r seattan and explain tiro nature,rf d to Ql'aaris record has dress providod to a:Je well o-a ar.
rrgantp a.-a r All rawantr sactllt ar an t a back of MbPm.
23..Ms diagram or additional wen dast3n",Eh:
&For GeopeohaeFT or Clo teal-Stomp Geothermal Wens having the sane You tray use the back of this page to provide additional well construction info
ct astruction„. OW-1 is tam Lnt&hate TOTAL NUMBER of wells (add'See Over'in Re'narlrn Box).You rraay also attach additional pages if necessary.rl.-
drilled:__ 24.SLIIIMITFAL fNSTRUCL'IONS -
9-Total well depth below Ltd sru area: /al tit.) Submit G0�-1 within_)?says of w ;rouap los&per the 3aalflawdmg:
Far nualliple wens list aid depths{(•t'.areveN(wa le-3{�!�200'sand aL ICU)
l CtbdE�ova? laird 6n�to of mew, / 24ot. For dells: Original team to Divisirsa of Water l esouross (DWR),
top , _ t1) Information ring Unit,1617 MSC,Raleigh,NC 2.7699-1617
$%ismertonsil ds above cat ft,,rise +"
it,Lot r: 41' 1/ _-4(1mr.) 24b.Far Weed n Wane:Copy ro 17WR,UndRegtoERE Injection Control(IUC)
.✓e Program, MSC,Raleigh,NC 21699-1635
12.Win constrection> ed: aid,, — Mt.For Water Sent and ea4 p Geothermal-VE�a.(etturn Wells;Copy to the
(i.e.Warr,rotary,caa1:45,direct pink,etc.) county iI.�SXSlSmenth L'k�i phitVil!t 1; 6II6:county Whore IY1R
4 FOR WATER SUPPLY.'4'WELLS ONLY: - -._..., .. .......-. 24d,Fur Water Wel r c�l..=€3�ova+r'l_On,po0 GPM.Copy to DW .CCPCUA
/�,� ,.9,{g�. Flub Prugratat.la MC,RB atg a,bic 2 o9 -166l 1
l�>9.�l )e,. S�. ". .�.a.... �Cf�iEitldd ate tit:, ,/ ;.� 'm .�...� '
LE18. .liacsn type: .., ��_...�ixan� L/• =-Sdoaomd�.,v_.�
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Form GW-1 North Casolion Depatmont ofErnvm r mcntsi Qtrrtity-Division of Water aestnir,lay , F'.+svis cd 6.4.2018