GW1-2021-07914_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD(GW 1) ForTniemai use only:
L.WeH Contractorhdbrmatioa:
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O 4?? 16 D�INSRCAS ORTUSiA[G
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Iivafi lidob/ewe/laavurradronperarr�(ie t77GC&m&. AftVariowp-dy tt is
3.Well Use(cbwk well use): $ tt hL
Water Supply Walk- 17.SCRtMN
OAgricadtural F130M 10 DIAl a slarrs� i >aA7�Bi6t
OMIMakta1/Publir: � � m.
Oeo G &-m;l ffi g supply) hAmdeffid Wat w Supply(single) � IL is
OTndostrial/Commemial OResidentad WaterSopply(shared)
Olin 'on 18 GROUT.
[1Wells>100.000 GPD >:soe1 Non-Water TOue .( + �vrn MOD&Aeroaxr
�PtYWeU: 0 R Zd IL ��►Ii(e 6 UPt1 P�
Monitoring ORecovery ft R
Igj edion well:
OAgaifaRedaiige a- MOCaotmdwatet Remediation
❑Agmfw Storage and Recovery O�y Beier 19 SATID/GRAYSLPACK e
FROM ro mrrrat�rci
OAquiferTest OStomiwatcrDiainage IL R
OEapmiraeE al Technology OSnbsidenee Conttol R n
Mood nud(Closedloop) OTracer 2D.DRD;U NGLOG attacLiddi aalafiee4sii
Da1(HeaLo�CoolmgReUrm) OOther(expiamunder$21Remads) >?soM in DE9CH�11ol�Tarior: �hat stne,em
/ � 't 7 'L �ir�= cdpn
4.Date Well(s)Completed:0 7 27( 21 Wen mp 7 6 n- M00 IL ( Rinr't
58..Wen Location: IL
l ML
�1'waW IL R
Faa7iryr/OeraerName Faa7ityIIJ1`(rfepp�ble) ik !t
Mr.&d Cfty�and TT IL M
Wilkes 20017ZS' 2J-
County ftcrl ldeoff=ationw0.(PMq
Sb.Latitude and longitude is degrees/minutes%eaonds or decimal dew
(tfwell field,am tatllme is set&cka)
22.Certification:
Z7 2/
6- )the wen(s): cut or OTen"rary S*MMre ofCwffied ttitfCancoc�or Date
7.TS Wisa repsirto an By-VnVdwforat.Ihoeby aer*fixItMeweD(a)was(were)corcolradedinaoeardmtewdh
e3is�wen: OYes or Mb 1SANCACo2CAIQDar-ISAJYCACO2C.MWWeIICarn&acffiwSftdflwtocnpy
$tlurisar rf1/aMibmrnw+dlao�ar a and hwbemprarkWIoNrauwfiauner. molmnir
repoirunder 2lnwrarb=cdai arcade baa grtusfona.
23.Site diagram or additional well details
L For Geopiobe/M or Closed l oop Geothermal Wells having the same You may use the balk of Otis page to provide additional well cousbu Lion ifo
won.Only 1 GW-1 is needed. bditate TOTAL NUMBER of weQs (add Nee Ovee mRemads Box).You may also attach additional pages if teary.
drilled
24. IINSTRQCITONS
9 Total well depth below land swf m 400 SUBMITTAL
For=awe wenx&W 4UatW?&-J- (zowwlk-3@2OD and 2@109) (fL) Submit lids GW4 wifLln 30 days;ofwM Completion per Ibefellowieg:
10.Static water level below top of m*r..GO` 2aa For Ali W� Oni;� fmm to Division of Water R (DWRI
1lw�er lePet isabane aam��use"�' (fL) Inhumation Processing Unit 1617 MSC,Rakish,NC 27699-1617
11.Boieboledlam :G l�� fin) 24b.For Iniecti a Wells:Copy to DW �R,U )
//�� n 1 Program,1tr36 MSC,Rahagk NC 27�1
MWell construction method:/�I t 1`o 1 ar Y
(—anam-wy-cow d-a paste,eta) 24c.For Water SM tv and Oxen=l con Geoihero�al Retain Wells.Copy to the
county®vao�l health depattmeolofthe ca�ty where installed
FOR WATER SUPPLY WELLS ONLY
24d.For Water Wdls rod over I tl/:Copy to DWR.CCPCUA
13a Yiad(gym) Method ofi� jr �- 1'�t�€J 1611 MSC, etgb, C 27699-1611
13b.Disinfection type: Amoual O O Z
Form Gw-1
NWh CawI=Dqww2cntofFnvuonrocnWQaahty_Dn mnofWaterRmources F Rewised6-&2018