GW1-2022-02990_Well Construction - GW1_20220302

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Cantraetnr Information:
ZOM
Nell Coat dorName FROM TO DSSCR>QIION
Nam CedHmti®Nnmbm r e '
✓Y(1�Tt'—� ��"nd\��i /� FROM TO DIANI818R TfRCRN84�6/ MnTERIN.
CompanYNama ft. Mt. L In. SfA Al
16.31011M ORTUBWG t etdased-t
2.Well Cwtstracdon Permit#: mom 1,To DIAMBM MRCKNM I MATMU L
List all applicable Weil coma icdan pawdl;(le-UIC,Camay,Slate,Var(ance,etc.) ft. ft• in.
3.Well Use(checkwell use): ft•
Water Supply Well: 17 tiCRS6N
FRM TO DIANUMM SLAW TIMMI.
Agricultural E3M allPublio O ft. f In.
Geothermal(14eating/Cooling Supply) idantial water Supply(single)
IndustriaUCommerclel Residential Water t (shared) s. I td
Supply 1&GROUT �
Iasi on FROM TO MATERIAL CFM1TMEMD&AMOUNr
Non•WaterSupply Well: �-
Monitoring ft
Ftgeefion Wen:
ft. ft.
Aquifer Recharge DGrottndwaterRanediation SAlVD1rd�VBG
I(Oleallhexrmal
uitbrStorageandRecovery 133elinityBarrier FPMM TO MATMUAI MMW a MMM OD
Aquifer Test OStormwaterDrainageExperimental Techaoiogy Dubsidence Control % tt.(ClosedLoop) Tracer 20.DRUMGLOG athwhadditionaldmebif
Geotht�el Coolie Return Other lain under#22 Remadts) FROM TO Dt3SCRn'rrON mlor aoahosk
1t. ft. lr�. -�
4.Date We11(s)Completed: Well w# v ,r' .�
58 Wen Lorna! s• ft.
VQ
FacilitylOwnerName Facility M9(ifapplitable) ft.
rdG Ji,.i
S.21 a» R.
pbvsi dress,Qty,and Zi ft. M
cofintV
QefSov� 2l.R�ViARI;S
Pahcel raentifiaationxe.(�>M !�- (; 1 r
Sb.Latitude and longitude in degreesin inntes/seconds or decinoai degrees:
(if�vall field,one latllang is sufficient) 22.Certification:
5.is(am)the wens) i;rmanent or OTemporary Sipstm ofCatified well Contractor Date
By stgnfng#*form,I hereby rrr 0 that the weA(s)tvas(were)a nmucted ht amordmtae
7.Is this a repair to an existing well: Gresor DNO with 15AMAC 02C.01W or ISANCAC 02C.020D Hell Construction Standards and that a
if thts isarelmb•,fdl out known well coma union Infomtatfon and espialn die naarre ofthe copy of dds recordho bun provided to ft wrU owner.
repair under#21 rmnarkssecdon or on the back ofd*form
23.Site diagnamor additional well details:
8.For GeoprobdDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only GW 1 is needed. Indicate TOTAL NUMBER of wells cOnM1c ion detelk.You may also attach additi"pages if necessary.
drilled: SURMEMAI.l1VS1'RUC O*9
9-Tetal well depth below land snifflace:_ C2`-/e� 00 Z4a.For M TVells: Submit'this form within 30 days of corn letion of well
Aor muidple wells list all depths if d{�erent(6=Wle-3@200•and 2Q1009 constructionto the following: F
10.Static water level below top of casings (ft.) Division of Water Resources,Information Processing Unit,
I/, it level Is above casing.nse"+" 1617 Mail Serv6 Center,Raleigh,NC 27699-1617
11.13orehole diameter. / _(in.) 24b.Por Inleetion W-M In addition to sending the form to the address in 241
above,also submit one copy of this form within 30 days of completion of well
12.aug ratuy.ckfr, method: construction to the following:
(u.cagey rotary,cable,ditectpnslr,ere.)
Division of Waterltesomms,Underground Ddection Control program,
FOR WATER BUITLY W&M ONLY; I6 5Malt Sea vQtie Cen1Pa,Rele3gL,NC$7G4A1b36
13a.Yield(gpm) Method of aftT Me 24c.For Water Sanniv&,10�16a Weft In addition to sending the fuim to
the address(es) above, also su6aiit one copy of this form within 30 days of
13b.Disinfection type: Amo>mt: completion of well eonstruedon to the county health depatuteat of the county
wbem constructed.
FormGW-1 North Ca bnaDepmunadafEatvir—tdQuality-DmmonofWawRmmm Revised2-n2016