GW1-2022-03730_Well Construction - GW1_20220330

6VELL CONSTRUCTION RECORD(GW 11 For fiftrad uie OnW.
. Y. C9ntractorInformation: . _
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• s 11 r/Yte� /S Cog Fin
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d 'r0 ' F-77
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WcMitrsctorNeme p @. '�r� • .
NC Well CootractorCeRifieatfonNumber o G forsnni6•ca+ediv'elli OT;LINEB a"' "b1E+'�'i,'`ir:%,'...7i
_�G9//1�/�s• T%c. FxoK To Dtnnmrtrt 7lrcravEss tdn7Eatnr.
Com Name 11 B' --0,3 ft.
P8°y' #16.'JPII�[iCASIIdG ]tTOBING eusieiniatelti�e"d�lod' is3G:YI,`E :;��+5"sAbc,ri�t
2.Well'Construction Permit MOMr - .To I Dranusrsn•I 7IDC@iFS3 staTsttw.
LfstaUappUcabte veil eonsbuadon permits(Le-WC County.Sfafa Yarfahm eft) D' &
3.Welt Use.(checkweit use): fG ft: tu.
I
aterSaPPlgWen: ti7.SCRE6NMc'n�i"? 36�h::5i?SY'F:}s?s�u"o�iq),�r,^•;7:i.'Br'ca:Z4ip•�-Fe'"'�?St'i�:a• 't
PAOMt 70 DrAM SLCTSIZE TStC1QlES3 MtATERiNL
Agricultural DMts icipaUPublic 0 fL ft
GeothemadOleating/Cooling Supply). [3Residential Water Supply.(single) iG fa.
IndustriaUCommaeteild tMResfden6l Water SuPPIY(s '2^s r+x,?F�.1. g- i ,sv ,�,...� <.
. i4ttFGADUTI�kt1.£i.. !."=�i..d.....i.,.''y;tt:?3a;'ii'•R�•.....bu9n"i4::p!..1
tiOII M(LK TO Tsnw.• mtvlrrCBawxrMtgrtrOD&
Nun-WaterSuppVWeU- �: 'L . o ft i �'
LAVIftTesst
g DR=very n f6 y 6 B
en: & ft.echarge �GroundwaterRemediatton•.' " rorageandRwovery 13SdWwBanier mom Toest j3StounwatuDtainege ft fGntalTedmology 13SubsidenceCoMolal(ClosedLoop) Tracer' :710.D LOGal olin ReturnrlOther(a mlain under1121 Ramadrs N oMr. To Di scas�rox cotoatmnta semsoek
A ft. a ft. RYd •
4.Date Wens)Completed: a/ `z Z Well WO I.A �, & q n rt,w a
5a.WCULoCRtion: ( IL
Vie • �-
�a 3 . IL Asa o D' +eL
PftM IOwner Jaaus _ FaeitOy ID0(ifapplteable). & D'
fL ft. MAR. 3 020 9 .
�rr�� .1J,4r�ne. .�?1 Cre�rinrrar� 1�1.L. >5'zL
PbysWAddass..Cfty.andZfp ft. ft
L `P Ga .�:� .�i::n1�: v' A?.$n"•+iGYiarrfi v•n�iars'P:.f��ic.�l7��,�'t`7�.J. +yYi; i� r.L c4
Comp• �— PatmIldenffndonUMPM
d a
5b.Latitude and longitude in degrees/minutedseconds or decbnal degeses:
(ifwell8atd.onetvtAongfsenIDelea4 22.CnIffteation: '
3d.�6ag n N 78'3G'�.2`t�6zy:r w
Si ov
.6.Is(a1e)tbewen(s) rrtranent or 13Temponry
,VI-
✓ Bj,Sfvft thfsform.•1 hereby Cae that the weJl(s)arcs(:van)eonr&reted to aaordmue
7.Isthisa repair to an exis ftwell:. 13Yes .or ON6 IVIth IMMICW.,01W Grim MIC 02C.02200Jr4ffC0nmaaToaStaadardsaad&Wa
.r&&Lsarepafr,JtUoatlmmmiwfi onstraettonfitfn=donaadesplafnthenatareofAe eopyojthtsr�rrllrasbeenprovldedrothenellaurrcr..•
repairaader#2lrenmrktseeNonoronthebaekofth&faros. 23.Sitedingramoraddidouldwendetags: -
8.F4r Geoprobe/DPT or Closed-Loop Geothermal Wells Laving the same You may use the back of this pap;to provide additional well site details or vSyQ
conMedon.onlyIOW-lisneeded.lndOMTOTALNUMBSRofwelis construcNondetetls.You'mayalaoattechadditonalpaP,esifnecessazy:•.
ted' AUBMI'1TALINBTRU(MTIONS
9.Totalwendepthbelowlandsurface: `/Gdd Z (�) 24a.For All Wells: Submit this form within 30 days,of'eompletion of well
FormdItptewe&IIstalldep#xjr trwvd(-ample-3Q200'wd2Q1W) eonstiuctioutothefollowing:
10.Statlewaterlevel below top of casing: VQ Divi4ton of WaterResources,Infbsmation Proce'sdngUn%
tf 5rararlevdLs abora eautn&use"a' 1d17 Mail Serves Cwter,RdGkAsNCZ7699-16t7
li.$otehoIe diameter: (in.) 24L For iutectim Wens: In addition to sending the Ibl=to the,addnss in 24a
:above;also submit'one copy of l ifs 1brm within 30 days of oumpictlou�orwen
It Well construction method: ' t^y�,�r y Const mation to lice following:
Oe.mgwmtaW.eabtG Oedpusb.etL)
Division of WaterResourees,Unde:gmundInjection Control Program,
FOR WATMSMPLY WELLS ONLY: 1636MailServIce f]ente4IWeigb4 NC 27699=1636•
Da-Meld(gpm) X b Method of to t: A:r � 24c.For Water Snonly&Infection Wells: In addition to sending the foun to
the addresses) above; also submit.one*copy of this form wiUrin 30 days of
13b.DhInCectiontypr.426r:n e Amount: 46 O 7-. completion of well coustimction to the county health ileparl cent of the county
where conshucted. .
FamOW-t Noah cuormaDepadmentoMVfronmmtalQuatity-DIvlatonofWater.P-0 i itevfudy2't-2016