GW1-2021-00483_Well Construction - GW1_20210210

Jan. 29, 2018 10:58AM Env. Health No. 6711 F.
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W=cQNSTRUCTION RECORD Cla-11 Fur IaterneJ Use only'
7.W Coaaactor Into non:
R R.
NCW CoeRatuCer/9fi'n/f lbur Number �/ 16:;t32Ft'ER'[A61dR9' maIXieaid.welfr-fdR 8l` !_..lihde"�-r`"'e.�
✓S /.� r // FVrat iO u. nl,1MLTER TFINX/IMS !U
C Neme " 5 DM'j I
—/7 QOR.Mtpdd' -14riuil:rluedai e..c�i.�-- -..-=T•
2.Well Conatructleo Pernitil: 3 3 / '�e To obwelea t7RGds'Sa
/,grallop}limb/emlltmmrvrnonpcam p.e UfC Covey,.hore,Yonara,�) . R. R. m
3.{Well flat(checklrell use):
Water Supply Wen. 10 rn: 'ar-• d.:c,» .r--:_e=z
n hurm A_....r'._.
_AgricWtmal ❑M ipeUPublic
Gedherml(Amtmg/Cooling Supply) ardentoil Water supply(single) It R -
_Indusbiel/Commaeial ❑Rdideatiil Water supply(Shared)
Irr' tiara ram wm.a¢xaer z
Non-Wafer Supply Well n. R tN f2
Monitn>atg It.
Injection Wen! 6
. Aquifer Recharge r]Gmundweter Remediation ft
19[SENfiAGaiLSGPECK __. ._ ..___.._._,:=�._y_ .-. ✓R_._.--.T.-
AquifaStwage and Recovery 080linity 8ercier ro NA7OnhL
_. Aquifer Tctt MStmmwtter Drainage n. rt.
Hxpenmemd Techualogy CISubsidemeControl f, I n.
GeorhemW(Closed Loop) ❑Tracer '2dD tafGLe3C aif"Adifaiei'
Gtathmmei(SfeetinyJCOoli Repent Ohtler a uddet 621 Reauea To noes
R ;
d.Date Well(s)Completed: Wen llle G R
_27
sa.Well Lotadow
yC
FaaciliylOrroerNine; actin'ma(if* ha) r R
Curl a a.
Pbp"Add..Cosy.rd Zip Q h
cacao' PeaallderY6eaieelds(FRd)
Sb.Latitude and looQRlde bi dtlinv VmiaHeLuconds w tied=[elgnew. 's a
(ilnelld ,an7edlye2u e.�tiem) L 22.Cc ', dos:
6.fall")The vrcn( ehim.nent or QTemporary 4ieoewcof ,6W wed Cco0cnr Ate
By,IpAea rMT f°m 1 becaby cony abr ehe aeWO aof Meet atev,eaJr Mariam
1'.is Ibis a repair to an ellstiag well: Wes rJaS. rkhtSANGCO2C.0100ar114NC4COIC.0200WgCmmnurg9aMtra�/6ara
(/,lArtrarrpvb,Jl7laa),mw,wd(mulrvuim,l Jmmrm.,axAerpfoee ehe nmmr olJ» 000Y a/rMr roroxeda DeenprowArAro Or mllonrcr.
npar urd r e]/.e.e b.am„or o„,he back o(ebfrjam
27.Site diagram or aJJifiaaal wdl det0ils:
L For GsoprobeMPT or Closed-Loop Geothermal Weir having the same Yw may use the beck of the,page to provide sddinanal cell site derails or well
enrttruction,only 1 GW-I is needed. Indicate TOTAL NUMDAFe of ueis construction deeds. Ym may also ahech additions.pago if neccnwy.
drilled:
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r__ e
9.Total veil depth brim land surface: � C 1 . Par A11 Wclk: Submit this fore within 30 der of
Farw:dnpe.dr,farwl dsrt,./A:pbear faagde. 'oad2WM) days eonlphhon of well
c®muction to the FaioxTng
10.Suits water level below top of Calling: (M) DWisiettof Water Ruourm,Information Proteaslug Una,
1If.Inrl v above aumg are'+" 1617 Meil Service Ceohy Raleigh,NC 27699-1617
11.Rarehde diametrr.
(lc (Y.) 246.For(nlecilaa WeWellyIn addition w amdueg(he Conn to the eddrms at
12.Well construetian rem above,also submit one copy of this lbmt within 30 days of completion of troll
seen.nasY.'".-hued peak aw CgnebVGiw ro[be f011owmg.
Divirim of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY wiTL4OlII,Y: 1636 Mad Service Center,Raleigh,NC 27699-1636
c
13e.Yield(gpm) 7- ►klkod of law. I C` - At.For Water Supply&Injection Wells: In addition to sending the from to
the addrms(m) above, also submit one copy of Iho form wllhin 30 days of
13b.Disinfection type Amount: Cj442 completion of well consttcoon to the courtly health deponent of the county
vehereeonalruded-
FmrsGw-1 Norte Caeotiea lktwsmaol a[Eauueemeanl Q,aluy=nwmonoMwltuorces Revised 2-22-2016 '
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