GW1-2021-04654_Well Construction - GW1_20210514

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WI,It CONSTRUCTION RECORD(�1-1) For Internal Use Only:
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Gary.Thompson `; �� 14.wA =
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4418-A PJ�A`( � 2021 `Ia fL $ 1114
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IL nUMMEMR OR-7912M
2.Well Construction Permit#:_- 3 wr I TO DU MUM
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3.Well Use(cheek well use): ft.
NaforSupplyWdl:
191110111 TO I D1ABn= FSLOT 1111Fs
Agdcultuml tmicipallPublic. f6 116 ta.
Geothermal(Hestinscooling Supply) ffRWdOW Wane Supply(single) ft. �,
Industriel/Commecciet Residential Water Supply(shy IL GROUT
krination FROM BIATE ZM4L6TSIHOD&' Otavl
Non-Water Supply Well:. fL �r� R t
Monitoring fL m "
ocuon.
. & fi
JA�'
giriferRtxharge OGroundwaterRemediation
u1fe1 St 19.SANDIGRAVEGPACK
9 ' Stomp and Recovery OSalinily Barrie FaoTO
OrTest C)StotmwaterDrabnaga ft &
grimentaiTedmology 13SubsidenceContfol f6 fLeothermal(Closed Loop) OTracer 2L DRIUMOi OG asideb-oddtdoffitsh aft Veothermal(Heating/Cooling Rem) .Other{ jam under#21 Reinarim) FAtoh1 To nsst�rmx
fL fL C
4.Date Well(s)Completed: ].9-i 1 Weil ID# fL n b t
5a.Neil Location: O ft: S a 64-Ob.1,fit
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FdolitylOwnwNoam FaOwW#(ifopptieoble) ft fL
ft. ft.
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5Tb ken 2LREDLARKS
County l'atcol identification No.(FN
5b.Latitude and longitude in degroWininotes/secouds or decimal degrees:
(tfweu field,one thong is=ffldew) 22.Cer dlieation:
W
6.Were)the weff(s)&*ermaaent or [3T mpotnry Signatam OfCbme4wen Centaetor Deco
By dgeing slits farm,I hereby—I&dear tie trell(sj true Onv*camfrnaed in aaeatdaace
7.Is this a repair to an existing well: Dyes or OT0 idth]SA NCAC 02C.0100 or 1SANCACOZC.020O WtffCbmfter/on&am/atdsmtd tharo
lffhts rsarepatr jHl aut6totrrt srafl e�unasflort asformtmfon mid erpfo/a sheaamrt ofshe copyofdrB mm dhw bem pmridedta dmirdie roes
wpatrwdder#21 rmmArjeci n open the hackgfddafotm }.Site diagram or additional well details:
8.For GeoprobdDPT or Closed-]oop Geothermal Wells having the some You may use die each of this page to provide additional well site details or well
construction,only 1.OW 1 is naded. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessmy. .
dulled: Ssua nTAL IT'STRUCI'IONS
9.Total well depth below land surface; ( ) ago For All Wells: Submit tiffs farm within 30 days of completion of well
r arnmldple,mil:fi talt depths ffdomtt(eratople-3@2Q0'and l?@1001 construction to the following:
it Static tvater'level below top of casior G' (fi.) Division of Water Resources,Information Processing Un%
rfa+aterletrr rs above caring an'*+" _ 1617 Mail Service Center,Raleigh,NC 27699-1617
IL Bore bole diameter. 24i.For Iniectiou Webs: In addition'to sending the form to the address in 24a
12.Well constractioa method: tb4 r^ti/ ►b,;✓ above,also submit one copy of this fern within 30 days of completion of well
construction to the following:
G.e.auger.rotary.cable.dueatpush.arc.] �
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC27699-1636
1
43a Yield(gpm) (Oct Method of test: • 24L For Water Sunniv&Iniallon Wells: In addition to.seadimg the fort to
c the address(es)above, also submit one;copy of this form within 30 days of
.13b.Didutsetion type: N`7b f� Amount: r 6 �z, completion of well construction to the acuity health department of the county
where constructed.
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