GW1-2021-00486_Well Construction - GW1_20210210

Jan. 29. 2018 10:58AM Env. Health No. 6711 P. I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only
1.WCdntractag Ltorm
j !to � 'I be, /l tlAi-WATPR.20NYS. -•:•_ ;-.=rte � � _-
t TO DFS C111F-rl,d^f
Weft COMWW )b= R. j ' rL
NC�(Weennce dark c stiRmim N/omnh)aIA,II (�J/•/ I '..�/� �J '311:DDYgITCABI2Ra' -- `
Pit) IL)f'11 N./L-ta r I�1 AMu �fi r(l9L IO FAOM DIA irRNL
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2.Well Construction Ptrmtla: F/ mom I TO I DIAMITFd 1Y N
llsrnll app+ir.b/e well rrvumanm pera,iu A.aoAwa,mJ R. R. W
3.Well Uee(checkn<n use):
Water Supply Will- :77r9lRtaMo -� - --"
momaLor•?•� 1U1 MA
: Agricultural QMi/m tic Q R. R hk
Cawthermal(HmtingiCooling Supply) ideminl WraWr supply(s�)
71aduslrisUCommcreial OResidenlul Watet Supply(shared) H:O - - -
'ITringfition afOY I-TO �.--ti.._ .._ti di
ANOMM
Non-Water Supply Well' n' R `jll a
Monitoring ❑Recovery R R
lujection W ell:
R R
Aquif<rftaharge [)Gmuodswter Remedimion Aquifer Storage mid Recovery OSAliniry Battier [ I To I suTmwt. EMPrACLM[NrM
lGeothervial
Aquifer Test OSlarmWAler Drainage tc R.
Expenmuud Technology OStbsideoce Control RGeothermal(Closed Loop) OTracer(Neatin Coolin Reliant Otherexlain abler 021 Remahs aacnvrmR aa.n au6m, --_ — —_
(aR
J.Date Well($)Completed:hr)4�11 a, Wen IDN R R jE�!•—�
Sa.Well Lucattom r%/ R'
IL
FMily/O�Iev lama PMIN m/((fapWfOr) R R
Phyi Adieu, . ,W FIP R. At.
Comb Pia Idemiiewioo Na(PIN)
5h.LAlilude and longitude In degrees/mtautesliecoods or decimal degrees:
_(irwal li6t tie larAmgit sufficient) 22.Ccrtifcahon: R
c /c' �S/c�4�%WSJA)
6.Ia(are)Ifm yroR(s)�Permeneot or OT—porary Stinanot ofterrified Well Contractor Dtw
By srgm.a rhir Jura.I hereby eenh dmr be wwl(r)nor fivers!ca,utrKlld,ls ac[ordonn
7.D Ibis a repair to so existing well: OVes or ONo wub1JA ACAC 02C.0100 ar IJA NGIC 02C.0200 WeB Coarrtcon,Savk4m4 and raala
If ha is.rrpah,fr0 ow taro.,wdr wmnuuoh1,Wwvoe cieder&M the mom of he e.py ofW,nrordh.c are.pmwAdso lAeur1l ounrr,
rrpmr.a 'ell".,.. or 0.the boot of'krJoan. '
27.Site diagram or additional well JetAlls:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the beck of this page to provide additional well site derai s or well
construclicit,only IGW-1 is needed. Indicate TGTAL NUMBER of wens comtructiondeWtk. You=yalso attach addiliooalpPFs if necessary
dNled / /- SIMMITFAL INSTRUCTIONS
9.Toil nrell depth below land rinse. /\ (RJ tea. For All Welk: Submit this form wititin 30 days of completion of well
For malap/rwdblvraq dep�h./dpemm/emmp/e.7�00•aN2®100') �Qrl�romnuetion to the allowing:
10.Sgtie waier level btlow fop of casing: ` C (R) Dtraion of Wiser Resources,information encesatug Unst,
/Jvmar(anal u.bae mrvrg me'+•' 1617 Mail SeMee CeMey Rahlgh,NC 2 76 9 9-1617
11,Borehole diameter (In.) 24h.For Infection!Vela; In addition to sending to the fibrin the address 245
72.Well esnsirutllan method: (;"I-•'11"rs.;g Above,also submit awe copy of this Plainswdlhm 30 days of completion of well
_`mg a m construction lD die f0llowas&
( lay,etble,akeel push el.)
FOR WATER SUPPLY WILLS R OFU.Y: Division.(Water Reeoarcet,Underground Injection Control Program,
1636 Mail Semee Center,Raleigh,NC 27699-1636
^t
139.Vicki(gpm) Method of test. Nc.For Water SaDDIv A InitcnoD WrW: In addition to sending nu Cam to
die addrms(co) above, aim submit owe copy of this form within 30 days of
13b.Disinfection type: Y// Amount: ` completion of wall construction to the cowiry health depamme it of the county
where Conslmued.
Fam GW-1 NoMCas 16.f)ep.nm dfEavummeersl Quality-Disvan atwaurRnosacn Revived 2.22-2016 '