GW1-2021-00199_Well Construction - GW1_20210125

WELL CONSTRUCHON RECORD(GW-1) For btemal use only:
L Wen Contractor Formation:
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WeaComaetarPimme PROM 1'O • DFBi:Bi[HOx
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2-Well-Comtraifion Petn3t fi: 9-73V L / Plots "M DIADIE-IH 71010EMOSS 1 MAXEMMAL
I1a:a0 le McBaon�iacfmnpaa�s fa t/rGCam*&aftV nmrM gic) R- R In.
3.WCH Use(ehecliwM ase): n R eo
Water SRQp1y Well; :;ia.� l
E M Im .r DUN&= swr= 71 MA>EMM
Dwitic4amffic g• g• to
PGOO&CUnd
Wunkew Wftr Sup*(�e) 1s C ourFROM 10 MA7FAQAAL MSIHOn&AMOiflffapplywent dR �p R `
_hazge __ GmandwaaReon
� p�ReCOYQy Barriw FROM 11D MA18BiAL EO�LA�fME7HtfDt [3SWmnMwIhaiuWW Tcchadogy(Closed Loop) OTraCex Retain) Offer under021 Remada FROM To Dix(ceam-
eeihmei<
R R
4.Date Well(s)Completed: / wen ID# R St�,V R
Sa/J�W /Location: { R R
1S�(if � r.•�(� R R
Fee1410wnrrName Feea7eyIIlS(efappliraLk) ft• R
Physiol Address,t3iry,aadTrp R R ^���'t�'�.� :�
Cowry 1'sCrl e�fixo
Sb.Latitude ttnd hmgittide is or dceonal degrees:
Cefvmu field.metaellmgiss ) 2LCertiSeation: Irg,-irr3tion processing U11,11
DWR Section
N Wal-44 ;�
6.1s(are)thewa(s)M ermanmt or O!'emporary C0°TM�m Daft
By sVang O-Joan,I.hereby—9&dW Bee wWs)was(Mae)eavt&-ud w aoeWdurne
7.h this a repair b an eats ft weD: Oyes or 'No wA ISA NCdC 0IC.0100 or ISANCAC 0IC.0I00 Weg Censbacfim S'andv*mod flirt a
Ifdwnorepair,fUmiAnownweAeouiruchmrbfornalmmideWkwthenameoffhe .afdwreoordhm been provz&dtothewell owner
.
T402freoder#21 rvwa*awffw arm the hwk4A&fonn
23.Site diagram or additional wed!details:
&For GwWobelM or Closed-Loop Geothermal wells having the same You way use the back of this page to provide additional well site details or well
construction,only 1 GW 1 is nmded Imiicate TOTAL NUMBER of wens won chains• You may also attach additional pages irrAccssury.
dam- SUBMUrALIlySf UMOM
9 Total well depth below land smfhec 3 f�� f (R) 24a.For Ao Wens: this form within 30 days of completion of well
ForamffgJe,we&Ed afl d9 da s(&B--d(ease-3@200•and 2@100') oanctruction to the following.
1&Static water nerd below top of msi%-.. �Y! � QL) Division of water Renounces,brormation Pnoomd*u6K
if Water ma's above no-1- 1617 Mail Servim CmUer,Raldgh,NC 27094617
11.Borehole ammeter: d (in.) 24b.For Iniedion Wells: In addition to stmdmg the fam to the address in 24a
12 w�oonstradion method• A 47"f1� above,also submit one copy of this form witbin 30 days of Completion of well
Co e.maser,may,�.diceetpask etc.) Conshuetioatothetollowing
FOR WATER S�7PTI.Y WELLS ONLY_ DtAsfan of Water Ram ee%Underground 14edion Control P rog ram,
1W6 Man Service Center,Bait .NC Z769O-1636
13a-Yield(epm) Method of test a9• Le,l` Y 24a For Water Sanniv&Iaferhna wd[c In adder to sending the form to
the addmss(cs) above also submit wo oW of this foam within 30 days of
13L Didafecfion type: I+ 4- H Amount: '1 a Z- completion of well-001IStFnctioR to the county health depattmet of the city
where consonetA
FinaGW--1 Ww&Cuol=DepumwmofEn mmenWOoddy-DivamofWamrrRammoes . Revised2-22-`1D16/
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