GW1-2022-01609_Well Construction - GW1_20220201

WELL CONSTRUCTION RECORD(GW-11 For Interval Use Only:
1.Wolf C®atraeler Information:
/
WdCosft"eName RDn1M TO DEBCI�Q'I14Ti ..�
R. tt
NCC Well Caamdar Certification Number/ ))
To DtAawm
r )ti fL O Ia.
CempaOy NatDe
2.Wen C astroctlen Permit!!: `-> /3fr d To DUPAL"M MATcsttnL
finatl Wp*abk%Wlco owdonperxatta f+.e. 11C,Cowry.State Variance,or-) n. fa bL
3.Well Use(ebeck well ere): tt & is
Water Supply wen: no TO Dusl�rax MOT sfa �ccav�s ef,►rava e[
'culttttal �MunicipallPublic ft. ft. la.
Goothesmal(Heating/Cooling Supply) Residentiel Weser Supply(single) to
IndustriaYCommercial Ultwdadal Water Supply(shared)
IVAN TO MATUMPad ACil1lfElerr AfC6HOD l AAfOO1VT
Nom-Watw Supply Well: K
Maui Recovery ft IL
& ft.
u Aq ifar Recharge E)Groundwater Remediution
Aquifer Storage aid Recovery 13Saliniry Barrier mom To NATERL" Xb9%ACKN3MM=BW
Aquifer Tact [3Stormwet�Diaiange f f.
E tparhenmtal Technology_. .. ,_.. ... „[�Sttbsdence Cantrvl 6
tieot6arnal(Cloud Loop) DTMcer PR
-
Qeomermah H ' ial Raturat Other lain under#21 Remalts At ro Bator .err eoe
R. tt
�.Date W III(&)Completes well IDq
Sa.wan LocsOoa:,
F�effity/OwmrName ,Feciliry ID0(ifepplicable) tt
1 41
fL -
Phys' City,sad Zip`
02Z
County Parcel
ft.latitude and longitude In degrea/mfnntestwconds or decimal degrees:
(if wroll Saki,om lnJbag v sufficient) 27.Certification:
.1419= N W
6.h(are)tbevrewslapermaniast or DTemporary Signature of M%ffi d Weli Conowtor Date
By siViag At+)h'K 1 Aneby cerrffy.d�t doe wep(r)was(Ware)oasmwW in aceondowe
7.h the a repair to an existing welt: Wee or 0 wide 1SA NCAC 02C.0100 or 1 SA NCAC 02C.020o well Cow&ucda,,Standards and duu a
If Ilds.k a ngsati}i'1I out kxovm wr/I coaumwaox lnforimaon aid w plaln the nature of dw c6P3'ojMk record hoe been provided to the wit owner.
rsPutlr wade 021 ra a rb jwwx or an due back of dkl6nx. 23.Site diagram or additional weft galls:
9-For Ceoprobe/bPT or Cloeed-Loep Caothernial Wells having the same You may use the back of this page to provide addititdal welt site details or well
construction,oa)y 1QW-1 is needed. Indicate TOTAL NUMBER of welts construction details. You may also attach additional pages if necessary.
drilled:—- -A
9.Total wall depth belew fend sodue: fj (dt)
For—1k0k Welk firs all depde y'djfe W(aumkoie-3©200'and 2@010&) � Far All wd1r: Submit this Ram within 30 days of completion of wen.
construction to the following.
!0.Static weer>e below top of easing:. (ft.)
iy rase"kw!lr above catty we:.+ _
Dlvlsloc of,water Raoarcea,.IDfOrvtatioa Processing Unit,..
l 1617
fl Borehole dlaseter.. 1Ka8 Service enw,Raleigh,NC Z76"..1617
�) 24bM For laiggOa Welk in
C '
addition to sending the form to the address in Isla=
above,also sultirnit one c of this_fo.in with.a 30 da "ofi c oPY ys otuplrtnon of well
12.,w�oeDehtiattlea Method: conatruction'to the foudwin
,La.sgger.,roftry,eabie,direct path,etc.) g' :,
Dividenof-Witter Resources,
ed Injection Control PrsgrarD, r
FPR WATER,,SUPPLY WBLLS U1VLY-, Mao Sources Con
. .: . . . r Rrfeetgh,NC 27694-1636
IX,
,kM(gym) Metbod of test: . 2*-FAX Wiser SDDDIV&Llectcon"Wells: In addition to sending the form to
the addretts(es) above, also atibaait one copy of this form within 30 days of
13b.DLdafeadion type: Anaoaat: �i'Yt completion of well construction to thee county-health department.of the coumy.
where constmetati..
Form G1W-t North C has bcMftmt ot'Savunntmotai Quality-Division of Water Resouroas Raviaod 2-22-201ti: