GW1-2021-07100_Well Construction - GW1_20210915

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WELL CONSTRUMON RECORD(GW-1) For Intimal Use Only: -
L Wen Contmehor Information:
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ts.narM C'�R.aR 1UBR�iG
2.Well ConstradioviPe mit#: 3a� (s� >� To E Mtn 1 7HFCwws �.
Mir all appNeaW w H ersabacd apma&ere M Cana.SWft Vwfal m eh;; tt. fe in
3.WeH Use(c"&vrefi use): e. (e is..
5f: wp.d
Weft: 17 SCRI=
lir
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lac 0 a tt 1a
Mating/Cooling Sopply) �ide�rial Wad Supply(sue) >: IL id
Wry�9(sue MGR(=
IBM to MMERUL MIMMt EMOD&AMOMW
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QRecovay 01� tt' B
&CCM
hge []CuoaadwalwRa�amion tt. R
Staage and R ecovery �ioityBarder 72001 mfGRsvS[.rACB MAmxrAr. 199TREM
Test OSturowwaftDrakage, iL IL
Teedmdov ElSnbsideoce Coated IL n.
(Claaod Loop) EITM— 2Lnxua nee i m afda""Ong draft tf
Geo>I>e�al Rehm - ( orderg21Resnads) 79MM To D oN I�aies.aaUrr,rt
4.Date Wdl(s)Completed:0 A-7 gzAv Wefi m# 24 L a \ f
S&WeII Laeatlon: tr' 3 ✓'S r4ltl+R
F —T Mme —�---- �Y EN c¢ ) a. �
h'l K� 10 �7s'a7 0. IL
n 3 a©3 �-
Caamy Pate a matiomfimw(PIIi)
W latitude aid ode in de,peea/miaaha/seoosda or dechaul degnmic-
(iwell Sad,eoe lam is sufTxieft) 22.Certification:
c�2• c,l� SP N W QQ
6.ts(am)the wefi(s)fgPeimnent or []TempamryWd1 CanLaaor Dote
By afg»irrg Lds form 1 hffebp cwr&oleos Ba w(il wm(woo coutrrdsd m aoaordmroe
7.Is this a repair to as exbft weft: OYes or - wdh 15A14CAC WC-0100 or 15AhrG4C WC.MW Wall Constraebw Staid Mdr ad thaa
1f8ds is a repair riff gat Gram wed oaoava—bfor—,and esplabr t aaaae ds oWy oldW raoad has bear provldedso dre wsUasvrer.
repairwubri2l serra*sscA im arm diebaetofd*fom
23.SW diagram or additiomi weII detafbx
&For Geoprobe/DPT or Uoae&lm*Geotbsml Wells lining the same You may use the bade of this page to provide additional yell site&b&or well
date only 1�1 a needed. Mode TOTAL NUMBER of wells �l You may also after$additional pages if necessary.
SQRII AL XIUKM
9 Total weft deprtb below land sarBseer 04 24a.For AM We)la Submit>I»s form wiffim 30 days of completion of well
Fbr mdtlpk w k hissaUdVft If4orwrt(cmwpla 3®200'ard2@IW) constttro lion to the lbllowiog
10.Static water level below top of cmxfmg: 30 (B.) Dlvhian of Water Bsi o ea,lnforamtion Proeeffieg us%
lfwaar lead k abow -Saw.,. 1617 MA Service Center,RaklSk NC 27b994617
1L Borehole diameter: (hL) 'r 2411.For leteetlon Wails: In addibuon to`sending the form to the address in 24a
12 Wefi .etlroit: �also submitone copy of t>ffi foam within 30&ys o�compiecwn of VMH
ere soggy Bey cable.r -pas6.ate.) T ooastrodion to the fdloe.it
Divbdon of Water Remuroea,u,&q rmmd I J..don Coatrd Prograst,
FOB WATER SMLY WENS ONLY: 106 MW Service Gaiter,BaIdg%NC 2709-106
13a.Yldd o p♦r) Method of test: W'Ici 24e.For Water Seaok&Bchction Webs: In addition to sending the Luros to
the address(es) above, also sew me,copy of this form within 30 days of
13L Dielafledtaw li Amomit Z eompletmn of well eoosticadroa'to the ca dy heatia department of&e county
where constrocW&
Fa®GW-1 Nmd►G`aolmaDepa<tmeatofFeuviraammral Qoa>n9-Divisionof WotuReaearees Fcviwd2-22-2016
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