GW1-2022-03475_Well Construction - GW1_20220323

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WELL CONSTRUCTION RECORD lGW 1) For hdmuduse Only.
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1.Wen Cat-tr-a wr Iafoimtation:
I'L ZONES
NeII Coa6uctorName FROM To I DBSCRIPIION
116
(Mr WWORIMUR
/A 16, L.tJ L G r d' ',e—, L, HBOM TO Drat TAofCK MW BUTERrab
- gG j Company PFamo fA ia.
q ' lS.INNBRCA3INGOR
L Wen Conshaction Permit* '1J 2— (/ FROM To MATERrar.
Ltat all appltaabtewatt cntislrus on penttits(Ir.UfC,Contay,Stare,Yitimue,etGj $. & in.
3.Well Use(cheskwell use): % flt ht.
Water supply wPell-. 17ACREW
FRixa Ta tMATt3RtAL
Agricultural DNlunicip K-011c O ft. EL !im
Geofhetmai(Heating/Ccoling SuMbr) a`Red&o6ai Water&*PIY(shWe) e. R: tb
Mustrlal/Commercial DResidendal Water Snppty(shared) 1�QtOUT
Irrl nn F80M TO MATIi$il;L. METHOD&AMOUNr
Non-wlratersupplpweri: M. ft'Lkd
Monitoring m c 7
ecdon Well:
ft. ft. 6
JAquifer
quifer Recharge �CuouutdwatorRcmediatioa
quitr?rSfrageandRecuvmy 13SallwBania FPOM T M$L'HOD Test 13StonawaWDrainege fL ftftedmentalTechnoloV DSubsidenceCotrul fL fiteothermal(Closed Loop) Minorr o.DUMINGLOG afiaehaddi ondalwdsileodtermel eating/Coolin Retnm Other l*under#21Remadts) '0' To DSSC1tnPsox actor mt►hodr c►L
O ft. tt. �+
4.Date Weu(s)Camplefed: 3"Z2 Welt M# 7 3 .
se.weuI.�anonn: 7
�DDf ��i7 rt GS s• ft.
facit wownerName FacilityIIJg(tf apptirabie) ft. ft, P
23 lUr✓y� llz C14c.I Wd A 271�-1',jb fL ft. 7
AhgSlaa'lnAd&wm6 City.mad ft ft. ft. i
9 7&RV 537/17 21.Rt3M3It$$
C=ty I'a;cnlldenti#iNo.(P1N) P
A.Latitude and longitude in degreeslmiat:Wsw=&or decimal degrees:
aEwell f!S .one IRNong is auffi ant)
N 7Q1� 8 •,Lr( I wp -
6 tare) lls we ermanent or OTemponry oftKa5ed r tutu
� 4signing rldsfam I hereby Ctxt¢y that the MU(s)was(were)CmrMered is accmdMwe
7.its tills a repair to au etdstiatg weII: Dyes or Ed+•Q with ISANCACOZC.0I00 ar13ANCAC O1C.0100 Wall ConstnwftShmdards and dmt a
ffrhls is arepalr,fill out la om web conmvadon inibn=Wonand cwtafaftenearteofdre copy Qf dlsmwrdha&bcw pranldcd fa the welt over.
repab•rarder#2J remarlsseetion aran thebaclC-ofthis form.
23.Site diagn mor additional well debAw
8.For GeoprnheMPT or Closed-Loop Qeotherml Welts to mg the same Yon may use the back of this page to provide additional well sife detatlls or well
construction,only 1 QW-1 is needed. ladlowtv IWALNUbWM of-wells cot nation detaHs..You Wray also attach additional pages Nnecessary.
drilled: IONU 2 L IN9TRtTC7T[1NS
9.Totai well dearth below land soffa= l ( ) 24a.For All Webs: Submit this form within 30 days of eompleftoo of won
Formuldple went W all depths ifcWerent(--pie-3 oQ200'mrd1QI0D)
constructioatotLefoltowin�!I
10.Static water level below wpofeastog: 2-el) ft) Dlvtsion of WaterRae
Jj,vnter level is above owing,use"+" tuoea,Iuformatioa Pmcesaing Quit,
�,, f� 1617 Mall Service Center,Ratetgb,NC Z7699-1617
U.Borehole diameter:_ Q (in) 24b.Bor infection Weds: In addition to sending the form to the address in 24a
12.Well eonstraction n sethod: above,also submit one copy of Ibis form within 30 days of completion of well
(Le.aamratuy.=W dh-tpusk etc) Construction to the f(MOVMg f
DhIsloa of WaterResoar6m Ifndergronnd Ddeearon Contmof Pa+o�m,
FOR WATER SE?PPLY�PEId,S fl1tiLY: 1636W Sal vit9 Cwtw•WOW KC$764NUM
13a.Yield(gptn) McIIrodof tt J b•)h �r� Water 3MMIv& Man Wells: In addition to sending the form to
1 / the addresses) above, a1SO gatiM t one copy of this farm within 30 days of
13b.Disin n type: /-"l rM _ AMD=h Lr S _ completion of well construction to the warty health depaiment of tho col ray
whereconstracted.
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Fawn OW-1 NorthCemtmaDepamnmtafEnvhomm�ateiQ�tity-DIvlaioaoPWaterReso`ntees Revhed2.02-2016
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