GW1-2022-03433_Well Construction - GW1_20220318

Jan. 29. 2018 10:58AM Env. Health No. 6711 P. 1
WELL CONSTRUCTION RECORD(GW 1) "
For II I X lti 11 Use Only:
1.Weil Contract(o 111formAdo
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Wdl ConnactorNaan
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ion abo II.
NC Well Camtae CuMcadon Number
fS;t)1Frk7tS4�it3' `midis UItLIlVEIY f_ bte ;� 'w^:•.,..,
FROM 11 TOq R, DIAMEf6A TH[ ESS MATERLtL
Compaa a - 1 V
:1:IIVNI+,1�'(.ASII QQOTHn1NC? Iher`mal:e!"w6d:loo`2,Well Construction permit#:�../V to I FAOH To or,�btrrea {`
4fsra1l applimble srcll eorurtvcrioa pemims nd.t7IC.Cowry.Stars,Yo nnce arc.) It. R 10. �+rL
3.Well Use(cbeck well use): R. n. to
WaterSupplyWelL• -
_Agricultural [}MunicipaUPnblic moo' ro DUIrrET SLOTatr� iuicrciaFss �54A.T ny,t.'-
Q R• R.
Geothermal(HeutinfICOOling Supply) identiat Water supply(Single)
_InduabiwCommcrcial
'deatial Water Supply(shared)
lion - r--^^'`.is�•.����:::�'z�=.;�-:._>��.�:� ..
FROM - -TO :,•-MATt:R1AL L11rt.At:&HEtir--- O .g\MOUNT
NOR aWaterSupP1YWell: -O
Monitoring � roy
Injection Well: n• R
.- AquifofRecharge, QGmundwaterRemedistion n D
AquiferSlotag0 andRecovery �Shcinity Barrits '79A1t1NGRA3'B>
tROhr TO dfAiER1Ai, aMPtA D/� D
_. Aquifer Test �StortrwaterDrainage n n
Experimental Technology Subsidence Control n n,
Geothermal(Closed Loop),_ MTraeer s30 p G7tbG eilaiaddltiopeihlitetr[rtitik;au"'
_Geodtemtot(Hearin 'ling Renon / Other lain uade[#21 Remarks FROM To DtSCRIprtON mtar aminnyretFsask - saz err,
4.Date Wells)Completed: J well ID# D IJQQ IL O O tt
Sa.Well Location: CZ0 R lG r i
Aacldylthvntt Name h.. J*'M'
FaclitrtDJt(ifoppl;cnWe) n R. r,. �.. a, .-
r
P}rysknt Addmss,Gry,and
Coaaty Patcelldeadficatin go.(PIN)
Sh.Latitude and louglinde in degreWMauteslseconds or decimal degrees: t "'
(ifwellfletd,anatadlmtgiasn�iraeat) 22 Certification: q D- ------------------------
ar ` a t-
6.1a(arc)The well(s)IOPermonent or [Temporary Slgmnaeo ertt6edWeDConCacror Date
By Ngrdng deft foss;I herolry eeno tbar the"ff($)um(faro)taufHrered rb occ&donca
7.1a1h1sanpalrtopnextsdngWeil ❑Yes or o wNh1S4NCtCO2C.d100orlSANGICO2C.48d0WellConrnrertonSlandotsbandrhata
(/this Is a repot►,fill ors bmunt sell emuruwah fnfarttia erpfotn the nafam ofthe �PYofrh+s nsmld Imo bran protiYdul m the trsl!owtrt►
repair Wer#2lremarlaiewm,oyonthahaektrfrMsfamr.
23 Site diagram or additional wen details-
S.For GeoprobeMPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional wzll site details or well
construction,only 1 OW-1 is needed. Indicate TOTAL.NUMBER of vLr is Consifttction details.You may also attach additional pages if necessary.
drilled:
L 3IIDMiTTAt INc'r'Rt CT1pNS
9.Total well depth below had Surface:_ ®D (h•) 24a. For All Wells: Submit this form within 30 days of completion of well
For mulapk trdls lul all depths Jd;02,e»t terotaple.3�tNf sad I�/dd)
eonstmction to the following:
10.Stadc water level below top of easing: (R.) Division of Water Reaou
lfwmar level isabint crrb%we-+^ rft4 Information Processing Unit,
lI•Borehole diameter
j l 1617 Mail Service Center,Raleigh,NC 27699-1617
_ (fn.)
24L For lniee_ W d1 in addition to sending the f wen to the address in 243
12.Well construction method:_ Pv 4 r►tr above,also submit one copy of this Ibmn within 30 days of completion of wail
(.c.auger•rotary,cable,&wl push construction t construction to die follavving:
FOR WATER SUPPLY WELLS ONLY. Division of Water Resources,Underground Injection Control Program,
r 1636 Mail Service Centel,Raleigh,NC 27699-1636
139.Yield(gpin) Z-7 r
Method of test. 01 24r.For Water Sunoty 8r IDleedoD Wells: In addition to sending the form to
the addrcs -)above,also Submit one copy Of this form within 30 days of
13b.llislnfeedoa type: Jl Amount: �iIL .S completion of well construction to the cotut health d
• udtere constructed. ry epamnent of the countyFormGw-1 NorteC—i-D-P nmeotafF-irameaul
QwtitY-DivisionefWaterRctourees Revised2-22-2016'