GW1--07869_Well Construction - GW1_20231205

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ALL CANS`'R[�T ` `I d:0' i1 GW®1 For Internal Use Only:
1.Well Contractor Wotmiflon:® ,
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Well Contractor Name PROM TO ON
-�Q` � . 4tit 15 jjm
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'...,>att^:�....:�:a-el h; t;r.*dtnrkr y_. _ I .. A . _._. _ ._..._.._....._ .._•
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2.Well ConstrucUen Perndt9: IJ'W 0 J65 f i LAI1 0 P _ TO _TM RIATIORm.
List allitegleable well ocnatracllon permits{la WC.Coto*&ate Variance,etc) ft ft. • br.
3 Well Use(check well use): ft. ft. I, in,
j vVa�a's�p�v Well:
1 ; , to ::4 W. :. a
t OGeothermal(HeatiFng/Caoliug Supply) diesiduntial Water Supply(single) `: i
ft. :Y. ' in.
Cllnduet rialIComme vial . DResidc ntial Water Supply(Shared)
DlniEatlon DWells>100,000 OPD _ 'PROM EMU: :,�„*mow
Non4Vater Supply Wen: ® ft. Iv ft. it Q ray '
DMoni g Recovery tt it cJ
'Injection Welk —
QA,quifirRe Recharge CH3roundwaterRemediation it
. ." `&.1 r ..i11E+`. i.`.n:fitA.RwIr"mi ce.-taiuz.."h�—l:c.,.-g, --.c-`•.,.-,,,i;'.. Y.e:z•r.cn-•,uksaw;r:
ijAquifer Test OSton nwater Drai'age ft. ' A. i "` --- i.
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Callerimeotel Technology Dsubsidence Control it is I i
DGeothcn nal(Closed Loop) Dom' 0l +► <..;
©QeotheAoaal :eating/CooliugReturn) DOther(explain nnden#121 Remarks) ERI DEs a i iasoo tsoe.aritaetw.;ta.1
4.Date Well(s)Completed:10I j13 WellID# , .3.5 410 ft .9 ray.if e. toed(
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Foc�iy/OwaerN & F /VP(ifeppllceble) it ' ft.3�14 0 d k �� iarnse, ri R11� �1��� it. e � ® � ��z3
PhystoalMtn,C.ty.endZip ( • to tt { EnformM.;bn Pra ;s URI
vialse, ►,fi �getG$ : , z j ::.:
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County Parsedld oattp=No.(PIN)
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i$cr8iiA i&owlav ar,Issaeizat 22.CtrMeationl
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6.la(ture)thtewen(s): t ermenent or DTemporarq S>JIo We .Contractor
Sy rlogthisJbrer,I hereby gee*that threv11 )was(wens soda ao onienee with
7.U this a repair to an existing well: Dyes or d&o 1&t MAC CC,0100 or ISANC4C 02C,o200;Well taon mietlen Srandaroyand that cam.
rthb Is a repair,fill out known well censtrection*matron cad awl the nature ofthe OW has bean pravtded ro the wetlait:t®:
repstr rarnago=WUon or on the back of this form.
• u �nr eiletzralre a.s.• r C fg •• CizotN rn::..a': ,:itS havi•,x.hn-+--+, i{-1 l.:n i7 lid\illy'\l-(4+S1L i,?ija .fl-k.'''`"1 itY"''s'A{lfl].-1Q.!Il f'"-""."""A'"""
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W 9 CQr •s.ligt.RY bf tlfl !°}. GtYv1�iK�a.iv�u'v.rv.luYa4W'. • J . •al .tIK�lfAll••� ._ .. L•. ..�f.?Il: .
ceasbuction,only 1 GW-1 is needed. lirdieate TOTAI.NUMBER—of wells fstd:E`See Over'in Remarks Box).You may also attach adni tonal pages if necessary.
drilldrilled a4,SUBMl3TAkINSTRUCTIONS
9.Total well t depth below land surface: g�. ( )
For mul!(plaw'!dial all depths Offense(example.s a( 200'and201009 Submit this GW Y within 30 days of Weil completion per the following:
10.Static waterkvel below top of casing: t)—D (�) 2 • For An Wells: Otfgintal Rtna to Dlvhalaa of water (DW8),
ifruterlevel is above emberuse"+" yt InSmmatimnProcra6ingUnit,t61 MSC,Ra1�gb.NC27699-I6I7
l legh t'zr.:.='i-:.,z.11.=/-:-.'..,e:.?tagsI 97.:4r..,,_..._a e:.d-,a "VT Ter.
Pe-
12.Well eonettime on aueUEod: Q i r- n . . r� =- 1
(Le y,chic,direct peek ere.) 24c.For. Water Sapp -,d en-LoopelmBtermaiReturn Weiss:Copy to the
courtly environmental+,: " ept'ofltire catiaty Where intilatJeh
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flWAfERSUPPLYWILS ONLY: ._t p d.For Water,W�{►ens producin ovsr t 0 000 Ch W enmitto' grem1611 MSC state NC 37699-1611 °PYmDWR,CCPCIJA
r� �, Disinfecttoa type: v l f 11 Amount 1(2 1 '