GW1-2022-03467_Well Construction - GW1_20220323

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WELL CONSTRUCTION RECORD LOW 1) For I AMIld Use Only:
1.Well CcmtrardorInformation: t
14.WATBIt Z<1N>IS4
IUeu ContrectorName FROM M nI1sCR>PR10rt
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;TO wat C. is MMrM Lin
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Compeny Name $. io. 417— //�
16.11VNBRt hSINGORT[IBII�iG dosed4 Y
2.Weil Canstraction permit#: s3 �D 1 7 FRo To DtAZiURM =ICK M IMATERUL
.tat all agpltcablewell cowlntcuon poWts(ir.UIC,Comtry.Starr,Vmfmm,eta)
3.Well Use(cherkwell Wei
Watersuplq well: 1.st�i
oM To
itrar i1aA1�RtAL
Agricuittual Q dP*?ubllo 0 ft. & j, i irr.
Geothemal(14eating/Ccotiag Supply) �denti d Water SVply(single) ft. ft. in.
ustrlaUCommerciai E)Residerdal Water Supply(shared) I�t OIPI'
Irri on MOM To MATMUL MtMOD&AMOUNT
No
1t2onit Ift k o N�`c
deamon Well: fe— C—
ft. fk
lAquiferRecharge �GsamtdwabnrRwneditttioa ]t1 tfi1MN VFd. '
Aquifer Storage and Recovtay f3Salfa tyDanla FROM TO BUTE EAL t3MpLAc Nf D
Aquifer Test OStornrwaterDrainage ft-
ExpedmeAtelTechnology DSubs1da=Cmft1 f tb
&Othetmal(G9osed Loop) DTracer 20. R=qG LOG attachaddttonalfti€
Geotheimel Coolin Return 01lrer Isla corder#21 Remarkd) PROM To D135CRiPTtOI4 Worn.ecLessmm
aoDhod
tt. ft- 11C o
4.I)ate Weti(s)Oomphded: ' 7'Z2` well 1D# ft.. tt.
go.Well Location: ft. ft.
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facdttylOwnerNamc Facility M#(iapplicable) ft. &
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county PatcelIdentificatianNo(PIl3) rnrE r! j 1
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61►.Latitude and longitude ft degresfnainateseconds or decimatdegrees: C u+(ifwell field.one Mi ng is sufficient) 22.Cc on
3oav-�t 3�7-22
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ti.Is(are)&a wells) ermanent or O€emparary SVCertified Weft r Data
7.Is this a to an �h 1 NCAC 02C 910 1�CAC 02C Well(Cmwvractian Wffel ato dards a
repair existing well: Yes or o
lfthts Is areparr,fill out kwwn well cons mcdon 1nf7n=1oaandespia14rhe nowe afther Oopy of tidsreeordhasbeenptwldedtathe well ownp;
repabrarder#21 remarksseGion anon ihebackafthis farm 23.elite diagnimor addidatisl well detaffs:
I.For Ceoprobe/DPT or Closed-Loop Geothertnat Wells having ft same You may use the back of this pop to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTALNUN BER of wells construction details_.Yon may also aback additional pages ifneressaty.
drilled:
9.Toial well d /r � SIIDit+IlT°FhI.IN9TRIICIT[N&
depth below land smface:_ (f� yy,For All Wells: Submit this form within 30 d of
Formaldple uw7s list all depths lygeereM(easmipie-3@2W-and2@10D) a3'8 completion of well
,v constructionto the following:i
10-Static water level helow top of casings 7 (ft.) Divdslon of Water 8�
if water level Is above casing-use"+" umes,Information Processing Unit,
1617 Man Service center,Rnleigb,NC2709-1617
11.Borehole diaamtes: 24b.1Pbr Inladon T+6eL1r+:: In addition to sending the form to the address in 24a.
c ova,a1sD submit one copy of this�within 30 days of completion of well
12.Well const�ctton naethad: t�b�
(La.aagmiotuy.cable,da-tpmk etc-)
y construotioato bite foIlowing:i
Division of WaterResamtiees,Underground Weefloa C wH of program,
FOR WAM SUPPLY WELIa9 ONLY. MG Mail StxvlOD Claw$fd4,NC2799.1636
13a.Tlfieid(gpm) Methodef te3t: a"` ZA"k" 24c.For Wow & - eat In addition to scudmg the form to
the addresses) above; also itibusit one copy of this form within 30 days of
13b.Disinfedlon type: f r� Amok �o N••4,�5 completion of IOU lonciruettoa�to the county health department of the comyy
wbere ew suacoed.
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FotmGW-1 North CawU.DWdmaatafSavlmn..WQusniir•Dh3 -ofWaWRes
Revised2a22016