GW1-2022-02983_Well Construction - GW1_20220302

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WELL CQNST`RUCTIoN RECORD(GW 1) For Use Oaty:
1.Wen Coonhuctorhhrm dons
ZONIN
WeU CochectorName FROM TO D1iSGRiP'II
xe wen C.'...
�At • M. UK
FRM To r Dram T�cltar�s TBt2iA1.
ft. ft, 1 6 ia. I ca)m�Jly xSama hs f,i. -
16.IlVI�t:ASII�TGOR d
?-Wen Construction pondt*_ W2 1 - 03219 oM TO mAaMUM raATSRfA�
Ust all appllcablewdl camncdonpoWts0,-UIC,Cooly.Stare /Vwf w;etr-) C ft' `�/ ff' f(,t in. 21
3.Wen Use(checkw ll use): tt. ft. In
Watersapiq Wen: 7.S R
Agricultural 13Municipambuo () it. �,
5
t�sATaRtAI.
Geothemral(Hei ing/Cooling Supply) OResidential Water Supply(single)
IndushiW/Commercial DRedii ntial Water Supply(shared) A(BtODT
1rTIMMon FRONT I To nmAT> ati>ptAc��rr ondcAdtoAtlr
Dloa•Waterawwwen: IL IM ft. P
onit Mg tt: tt
l eclion WeIIs
tt. &
AquifwRocMV DCmundwatorRemediatfea
AgulforStompandR=oM j3SalfnftyDatricr �71
id T�P �
_� N1 r,
Aquifer Test OStomtwaterDrainage D- ft
Experimental Technology DSubsidcace Co=I ft. ft,
Geothermal(Closed Loop) CITmcer 20.DWLLDiGTAf:atfaehadditiomts6e ds'
Geothermal Co Rctam) 1>do TO DESCREMON war smvmdc
ft. ft.
4.Date Wens)(3ompletd: 2A WenM#
,��lsalr\ eclCnnan ft &
MAR 0 2 702
Facility/ownerNamc Fa«tityM#rifapplicable) ft.
6?2 l J;112� DgHrAyn MG 2?70S
anySiCHlAddress.t�r,andZip (t. g, �i'+�`Vr`;�Ja9lllrry ` ..
CoUM9 T— PmcelIdentifiiationNo(pI13}
ft Latitude and.longitude in degrees/minuteslseconds or decimal degrees:
(ifwell field,one Imam is sufficient) 22.Certification:
201 1 3-1 Og
6.Ts(am)the well(s)PP"n anant or E3Temporary Sigaahue oftbttifie elt ar Dates
By signing this t,1 aertljy drat tltts weA(s)i9aS(were]caesitiicted in arrardartta!
7.Is this a repair to an egstmg wen: 951es or ONO mvith ISANC = 00 arISANCAC 02C.0200 Nell Conurmd=S tuidmds anddwa
1f this is arepair,fill out down weft cansaucdan injbnw ion andexphtitt dtetwttveafthe copy of this been provided to Me aamsna:
repairuader#21 remarbsec4lon aren the backvfthis farm. 23.Site diagramoraddiflonai well defail9:
8.Pbr GwprobeMPT or Ciosed•Loop C,eoa=Tz l wells havimg the same You may use the back of this'psge to provide additional well site details or well
construction,only I GW-1 is needed, indicew TOTAL NUMBER of wells wnshs Man detttt'Ls_.You may also attach additional pages ifnecessans
drilled:
4.Thtal well deptle below land swfaces 7i� (ft.) 24a,For Ali Wells: Submit[his form whMn 30 d of co
Far mddple wags W atidepthc ifdff-mt(e�aainple-3@2001 and 2(a)100) completion of well
( constnictiontothefollowing:
10.Static weber level below tap of casings L( {ft.) Division of Water Resources, Pro Ywater lave[is above oaring,use"a-a eCenter,Raleigh,
27619, i 6 Quit,
e
1617 Mali Service Center,Ratdgb,NC�'1�-16i�
IL Borehole diameter. (,,) 14b.Fox-Infection Wails: In addition to sending the form to the address in 24,
12.Wen conshvcfion method: abo►also submit one copy this fOnn within 30 days of completion of well
(Le.aum-wy.cabk directpasl,em.) eonstrucgoat0 the following
FOR WAM OUMY W&M ONLY: Dlvlston of WeterResomesev,Undaweoimd7idection Cmh d Progesu,,
1636Md9476Ceniler,Raleig XIM N16M
13a.Yield(gpm) Method of test: aHtaAmO 24c.Phr Water&M dr, InW ft Wen_ Ia addition to sending the form to
13b.Dis3afa On type: Amok q t7 Z tote sddress(es) above, also=6miE one copy of this form within 30 days of
ledon��constriction to the canary health department of tee w,,W
FommrW-1 Norarcarolmanepmun-tafErvir mmmtaQ=UtY-nh==ofWmrResomsas
Revlsed2-72 2016