GW1-2022-03429_Well Construction - GW1_20220318

Jan. 29. 2018 10:58AM Env. Health No. 6711 P. 1
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WELL CONSTRUCTION RECORD(GW_1) For Internal Use Only: ,
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WellContmctorName
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i FROM .... TO -DIAatErER" TRtMESS TERml
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L Well Construetlou Pernxit#- ••7 7 a• FROM To TRtcKMU i MATERIAL
l tjrall apiriim(re,odl ten:tnk6on permlu P.O.t11C,County,Stare,Vahanee.erc.) O. ft. In.
3.Well Use(cbeeknell use):
Water Supply IVeD:
u fro ^�n tx --SLorsme Tu[cxrtrss MATERIAL
_Agricultural MWicipaypublic 0 ft. R in,
Geothermal(Rcating(Cooling Supply) Residential water Supply(single) ,;. ,L
rndustrial/Commcreial Resideatial Water Supply(shared) yg dROtIT==' w y°- ^-'w'�:Y^ 'i.�-- - •- r�
Im lion FROM To MATERIAL I larracrMrx_rM=GD ae uuowrr
!Yon-Water Supply Well: 0 rr 30 +rr. ' W
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Monitoring QRecovery R Rt
Infection Well:
_ AquiferRechargo QGmundwsterRemediation
Aquifer Storage and Recovery 0SalinityHeerier TM'd TO MATERIAL EMP4tCCMRPrMQ7ton
AquiferTest QStormweter Drainage m ft.
Experimental Technology CISubsidence Control tt &
Geothermal(Closed Loop). C)Trwer (L-IMIX Kadt'tG eAZ;mQdt(to�eiilimt+-
FROM TO ftWA1FT9N4 celor,hardnnc,soah9ctt�ytnrTdJnAw.dc.
_Geothermal(Heating/Coolin Renunr30ther Mlatit antler#21 Remarks O fr. u0 R
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4.Date Well(s)Completed: a Well M# a.: Q R rQ
5a.Well Locations 60 1 U6ft QrOL
Fae�IitylOwaaNawe — Facility IDtt(ffinhobla) & D.
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Pby*WAAddnnS City: tip ago i(V
County Pan elldemR6rbtitia Na(PIN)
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Sh.Latitude and lobgltude in degreeslmioutes/seconds or decimal degrees: / G '-
(irwell geld,am lar/4a+g is sufficient) 22.Certification:
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(3�W
6.rs(Are)the well(3) Permanent or Temporary SWaure ofetaillied Well Contractor Date
By signing this jom4 I hereby eero rhar the trelf(s)uw/Mom)eontmrend ai acemdoace
7.ri this a repAlr to aD a crating wdl: Yes or 1Vo wfth 1-U XCAC 02C.0100 dr 1SA NCAC 02C.0200 Welt Cowtntedon Staodor&and that a
j(rhk/rareptrh jlllora brous+wdt aonttrutxiattbjrarawrian and splam the nattae ofthe eopyojrhts roaotdMs been protvdsd ro Ras tvenowttr►
reparrurders2i reamrls union ortin the bactofftfann.
23.Site diagram or additional well detAlls:
&For GeoprobeMPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only I GW l is needed.Indicate TOTAL NUMMM of wells construction details.You may also attach additional pages if neccunry.
drilled �f SMMIITAL INSTRUCTIONS
9.Total well depth below land surface: 11 4 0 (h.) 24a• For All Walla Submit tiffs fbrm within 30 days of completion of well
For mtdnplevens/in all dVUildpexmlafihos.3(a)700•md2@100•) coastructionto the followirtg:
10.3tadc%rater lever bdow top of casing: 3 (fL) Division of Water Resources,Information Processing Unit;
!wwar level It above emog we"+^ 1617 Mail Service'Center,Raleigh,NC 2709-1617
IL Borehole diameter: 10 Y, (in.) 24b,For Infection Wells: In addition to sending the form to the address in 24A
12.Well construction method: Y► above,also submit one copy of this form whiten 30 days of-completion of well
(Lm auger•Nary.cable,dot push,clo.) �� construction to the following:
Division of Wafer Resoorcta Underground Neetlon Control.Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Servica!Centd.Raleigh,NC 27699-1636
13a.Yield(Eptn) oe : . don WeDs: In addition to sending the form to
the address(cs)above,also submit one copy of this fonn within 30 days of
13b.Disinfection type: r( Amount completion of well construction;to the cotatty health dopartment of the county
where constructed.
FannGw-I NatkCmrrtkaDgmws dtofEaviromneam!Quality-DivisianofWat"R soarep Ravised222-2016'