GW1-2022-02994_Well Construction - GW1_20220302

WELL CONSTRUCTION RECORD f GW i) For bternal use only:
1.Wen Contractor Informw.
maado � ,,/�
Tom ,�. be- l IA WATBRZONBS
WeU Cautc AW N=e PROffi I TO DI MMITM
B. t1.
1116
xc coat c mrC—aft
1.1 _�I S !n r FSOM TO I THFCSNBSB MAVIrd .
ft. ft. I m.
Company Name 16.HmemaCASING`ORIm mm clamed-1
owl
2.Wen Consk action Permit#: FROM TO DrAMt R TMt MATIORAL
Listal(appII=bleuvllconatrttcdoapr4 ts(le.Rx Cormty,Stare,vat3mue,etc.) O ft. 70 R• I WC.
3.Well Qn(elteckwell»se): ft. ft. In.
Water Supply Well: iT:SCR>16s1 -
FROM TO D TaRW.
Agrioultw'al E}Muoichditbtio
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ustrlaUCommemiei Residential Water Supply(shared) A GROUT
1JT! on FROM TO MATERIAL EMPLACEMENTMSTriODdcAffiOUNT
Non-Water8upp(p Well: ft- t
Monitoring ft' t�. 4/ gypy
a�Ile
Ir Wdon weQ: 12
Aqui€or Recharge 13Gmundwah r Re nediation IL i 1u
19.SANDICA&MPACK Ucidd
Aquifer Storago and Recovery 133atiw Biurier FROM To MAT RUL SMPLACMWM OD
Aquifer Test OStomiwaterDrainage ft. tL I
Experimental Tt cimology OSubsidence Conwl ft. ft. -
Geothermal(Closed Loop) DTMcer 20.DRII.U0LOG lethich additional shedgEnceparA
Geothermal t-oolin Retain Other(explain under#21Renualm) FROM To DBSt`rtiPr! sott/mdc
/ ' ft. ft.
4.Date WeU(s)Coatpieted: I /7���' Welltl>g A•q 7�1� IL3,0
it.
,.._.� .e
5a.{NeA Lecs6on:
It. ft.
Weal_ UsmaxxO Luna ll ft,
Fac�ili�erName Facility MO Cif applicable) ft.
%ydnl Address.Clw.and Vp ft. ft. 'a3^abrl r= r E
�p es or 21.REIISARE$
County ' V V1 pIdentificationNo(pII3)
5b.Latitude and longitude in degrees/minnteslsecomb or decimal degrees:
Of well field,one iaUlongis sufficient) 22, tip;
�G,•33LA7Z x 7$•132�tg,� w
- C 3D2cf_ j- /2 . 2Z
6.Is(are)Ilse weIl(s) ermatten or Temporary oftketitied W r Dare
pair aApt
e9s � ivltk II NCAC 02C 111 1�AC O2C.02W Well Comiucift aSta idevds aned In ddt at a
7.Is this a n bo an well: Yes or v
If this is arep dr,fiUoutkm m welt cvmmcdon tnpnmulon andapratn the natareofthe copy ofilib recardhasbeemprovkWt to ft well o wtter.
repair w der#21 raawbsecdon or on the back of this form. 23.Site diagtgmor additional well details:
B.For GeopmobelDPT or Closed-Loop Geothermal Wells having the same You may Use the back of this page to provide additional well site details Orwell
construction,only 1 GW-1 is needed. Indicate TOTAL Nt1MBER of wells baron detaN-.You may also attach additional pages Nnmwiry..
drilled:
SURMITTALMMUMMS
9.Tetal well depth below land saffacet 'R o V 0L) yqa,For All Wells: Submit this form wiildn 30 days of completion of well
FormuMple wells Ustalidepths lfddivew(eavapte-3@2W''and2Q100) eonstruetionto the foilowing:
10.Static water level below top of casing: lanc� (ft.) Division of Water Resources,hilbirmation Processing Unit,
if water level is above mains,use N-" 1617 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole diameter. (iu-) 24b.For Infection wells: In addition to sending the form to the address in 24a
12.Well aonshwAhm method: above,dw submit one copy of,this form within 30 days of completion of wen
(r.e avJm ems.eabk akectpoda ew-)
construction to the following:
Division of weberResoorees,Underaround Iglectfon Coatrol Pr+ogemp,
FOR WATER SEtMY Wain ONLY: 1(t35 Mail3a vit Center•,Releigh,NC x7G49.1636
13a.Yield%pm) Medied of UW 24c.For Water Supply,&Ihjeetian Weft In addition to sending the form to
-7 the addresses) above, also submit one copy of this farm within 30 days of
13b.Disinfectlon type: OZ completion of well construction to the couwy heath depamaent of the county
Where Constincoe�
Fom►GW-1 NonhCwoUuaDepamnemtofB-I-mmtdQuUty-DhidmofWawRwautm Revised2d2-2016