GW1-2021-05587_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD(GW 1) For lixtermilse --
L(wen Contractor rmtdon:
Well Cottnac rar Nome FROM. TO DFSCRIPftON
I� fZ IL
0�4 AN IL IIL
NC Well Coau eWCerdficationNumbtr
j&gUTL8 CASING. jibblEcned weds t1R3:11c1BR' `?
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Vwilfr •N�yKr FROM TO MANIMM
Comp ay Name
2-Wen Comdracdoa Permit#: > . TQ nIAMETER "TIUCK11 M j MATERIAL
List all appdamble well amy&uetfon powd a(e.UIC,Cormn:State,Variandve etch r, '6. �r Im S G41 00 L
3.Well Use(check well use): tt. fL id r_
:17:SCREEiV r ;:Y
Water Supply weir:
FROM : T.T0 I DIAMETER SW?SFQ3 THIrx�FSS, brATERtAL
Agricultural [3Mimic'rpaljit hL
2 2. ,. �y �c.1�yd x
Geothetmal(HestiogtCoolmg Sw1y) Wmidential Water Supply(single)
Industrial/Commerew E)Residendal Wow SapP1}011aled) iB ItoUT
hTigafion _. 1ROM: TO MA EM1%A ME HOV,&AM017W
Non-Water Supply Well:
Monitoring_ Recovery ft. ft.
Injection well:
Aquifer Recharp E]Gm mdmter Rernediatian tt
AgniferStorage:alditecovery ossfi4Baraer 4pm TO r
TO MATERIALEMM ACt AERTMEMOD
Aquifer Test 13&ormvvaterDminage
Dgaimental Technology. Subsidence Control' tt. fL
Geothen1W(Closed Loop) OTMcer zo�ieurnvc r os.;msri. "Wo a.l «t.tc
I'Geolhurfal Coo Ing Redun Other lain undea#21 Remo&s FROM To nEseRn mN s W-& ere.
4.Date Wdl(s)Completed: /d f Z.Z Wen])# ft tl.
Sjq.AWe a. IL r
rct.�.l Avis ,
Facility/0w=Na= `` __ FacdilylD##fgplwAble) R, ft.
PhpidulAd ess,GIN and TrP 8
Conroy Parcel Dion No.(PIN)
5b.L*udeavidlongitudeindegreeshuhuteelsecondsordechoa ftrein: IC;f�3�T3l tteil ro`. �o
(if well Eeld,ow Wlw g issul&ient) ,v
N W
�a LZ
6-b(are)the wWS)tWPermJmWt or TSADporary Sigoeaa a ofCa6fied Well Canaamr Date
B}'xige►inB`1Lis farn6 3henmbq iae tify.thW dX MN(a):t=�ive�e)aa+tifr MCC in A=rA2=
7.Is this a repair to an existing well: ®Yes or Wo i►4th ISA NCAC 02C.6100 or ISA IYCd 2C.0200 Well ConsnaUion Shmdmds and that a
Ifthia is a repair,fill aar brwm well canwac iaa b#bnMatilin add eWWn he►WU,*of dw ropy afthis'iec�wd has been provided7o xrll oamer.
tipep+'war#�lirman4saeettmtoranliiebackaj'thZs,fornr, :
23.Site diagram or addHional well dam:
8.ForGeopmbelDPT or Qosed=Loop Geotl►etumt Wells having the same Yoo'may ase the bade of this page m proVi&addWond well site defy is a well
construction,only 1 GW-I is needed.'fiesta TOT�LI:1�TIJI�BER of�evells: coniftuction des: You may also anaeh additional pages if necessary:
drilled:
— — � SUI;MTITAL IAISTRUCTiONS
9.Total weil deplt below'land surface: �^�'S (f>4) 2ft-For�We>h. Submit this form.wide 30 da
Formal:iplexrTlsllstaUdethsengrr(emmprc�3®200.'aridl®lam --� YSpf completion of well
construction to the following:
10.Statle water lewd below top of essing. ' I Z. . (M) Dhrhtion-of Rater Resources.1"brmsifon Processing Unit;
Ifiuit�lrveltcalmvizmrare"+
�1 1617'Ma0 ServlceCeater,l ,NC 27699-16i7
11.Borehole diameter. 1 ,(� (in,) 24b.For blectilm in aM"to sending the form'to the address in 24a
12.Weli'eonstrnetlon.method: K above,also submit one copy of this form within 3fl days of conlpietion of well
construction m the following:
Cre.cuss,rotary,cable,diteci gash,etc.) _ �,
Division-of Water Res m=s,UndeigroundInjection QWtMl Program,
FOR WATER SUPPLY WELLS ONLY: !,t P 1636,Mail Service Cep,Raleigh,NC 27699-1636
11L Yield(gpm) 2-o Method of test: 1' \�!' 24e.For Water$umw&'Inieetlon-Velis: In addition to sen(iing the form to,
Tire addss(Es)shaver else submit,one copy of this form within X days.of
F0rrnOW-1 NarthCmoliaaDofEurnomnmialQualax-Ditiof 1Ramnoes LLB. i31