GW1-2022-05904_Well Construction - GW1_20220627

Jan. 19. ZUIU IU:7bPIVI tnv. health - PI0. 01i l r.
r a ForTntemal Use Only:
ri WELL CONSTRUCTION RECORD(GW 1Z
1.W I CaotractOflufarraatlo : �� _ -- ---GI, ' � fK.Ir,TL 1 e?A:wATg[1201vtiso===
{ MOM TO DiSLRIPrtON '
WcflContrectorName• �( ��ie 1)U RI. 5 cr~1
s. ti.
NC Well Conant rCertification Number °R:13 0.1ITER'GASL'iGG flirin dti.aiid 'ells:Olt:Ltne it f-ii u .;bre": .--t"`_•: �.:
� i S Dr OER TH[ ESS6`o 2/rs i Jil w4 $ i,øii2 S' r-ulf e it. it ia' 5,DRi1S lJ`-'
Comprn `'ma• 2.WeUConstrucdonPuadt#- ItiEIIVNSR.CASIY( OItTE)A1MG:(dedtherivat: sd loop!
s 3 FROM TO Df atEft TRCC
lt: it1°
/,Etta!apprmhle well emuunerion permits(te WCCounty.SantVariance.etc.) In.O. h _
3.Well Use(check well use): • �: =-c= _04
Water Supply Well: FROM TO BLOWER SLOTSIZE TLiCKNFSS 61ATFAUL
_Agricultural [} ICipaUPublIC 0 ft. R In.
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Geothermal(gentinp�Coolmg Supply) Residential Water Supply(single) R, ft. in. -
�tResideatial water suPP1Y(shared) -=K::= ": =-"= :"""
LrdushiaUComotercial 11 -785OKOU2=i-=_ ; •
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FROM TO tit SERIAL . TranscrantrratEriOD&AMOUNT
iYoa•{Yater Supply Well
ciMantmring [}Recovery - R• 4.
Injection Well: It. rt. _
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•
�Gmundwater Remedietion '°"•"
Aquifer Recharge � �K�._� .—�9lSANI)1GRei?PBIiP.YL' Favpticiitilt7*F �'-:L;-`" "
AquiferSto Sall Banner FRO' To MATERIAL EMPLACCMENT1Mr111OD
and Recovery d nilY R
_Aquifer Tat 'fStormwaterDrainage •
Experimental Technology
Subsidence Control r` ft.
DGeother1n (Closed Loop) OTraeer S70_11RIC INN11816NifaiSaddittohiLifieeiTrIfeeFs'icrs'g_=-`2'="V'ry'
FROM TO DFSCIIII ON mlenherdnear.wlFroek r• : .,rite etc.
f Geothermal(Hcatinp/Caoliig Retnm)f)DOther(toralatn dotterel Remarks) `�'�� •
�,1�/or� Well ID# - n
4.Date Well(s)Completed: n h (�d </Q f
• 5a Well Locating: L/ Y/ J 1/ '/1 7�� �S ft. G/ryc�v�r�`�
LrL 3��.// f/ 0/M.4 I 9/ CJr OJ aC h �j�n�s ! 1, ,' - 'r ,,, t,.
FaalitylOWIletName Facility>DO(ifiipptim:We) 75 ' *•?mow•'fi,.,ti s l P ate _.
• • l d)S ��/,�. °/ &'em /(i,'��� 5,a5‘' .
p iral Address,City,aed'tip __ 7�.<:?.y•r: ^c. _.77:.PeuelldeetifieatianNo.(PIN) "lJ L'
County D V`-10.li:OG
. 5b.Latitude and lobgltnde in degrees/minutes/seconds or dedmal degrees: Certilieati0n: �� a"
(ifwell Held.on Ulm is sufficient) guii,-6vi.,_‘7,2,4a_2.
3sd /II 'I/ N /- o .93 -w fq�(���,. �gigoatmeolktrt;GedNeUConaacsor Da
6.Ts(are)ihetveU(s) Pertovnwt or [Temporary
By tinting this Joan.I hereby ee'rOjy than the we(s)tsar(were)constructed Ot aerordaace
lRN with 15A HCAC 02C.0100 or 13.ANCWC 02C.0200 Well Ca utnratonSlatxroirit and that a
7•hisi,e repair p01011l era Imam
tingwtrr Dyes or 1Vo copy ofthis.vcandhareeenproiidreirothatte',comer
(/rhiclrarspah.JtOaminou+twdreomnucrianrnfarmarionmrdexpla0trhenahmtofrha
rpnrndee2l wrarks radon or on the hack clearfown. .
_ eag r a 8.For GeoprobtlDPT or Closed•LoopGeatherntalWells laving the same You may use thy back of this page to provide additional well site details or well
consauCtian,only 1 GW 1 is needed.Indicate TOTAL.NUldri11R of wells
construction details.You may also attach additional pages if necessary.
- drilled sunoUTTAL iNSFRUCPIQI
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9.Total well depth below had Mace! ..2 S (h•) 24a. Far All Wells: Submit this form'within 30 days of completion of well
. Foro tapfcanna(uraildepduild11erenr(tsmn,M.3@200•andi(gl00) constructiOn to the following
10.Static water revel below top dosing: (IL) Division of Water Resources.Information Processing Unit,
!floret level rr above caring.use 4-- 1617 Mail Service Cebter,Raleigh,NC 27699-1617
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11.Borehole diameter: la f1 .( (In) 241t.for Infection Wens; in addition to sending the fon;to the address in 24a
t f above,also submit one copy of this font within 30 days of completion of well
12.Well construction method: (Q� ` construction to the following: _
(Le.auger,Mary.table.ducat push.eta) -
of Water Resources,Underground Injection Control Program,
• FOR WATLR SUPPLY WELLS ONLY: 1636 Mail Service Centel.,Raleigh,NC 276991636
t
130.Yield(gpm) Method of test /3r --t,,_-.�. 24e.For Water Sunni,'&Infection Wells: In addition to sending the fort to
/� the address(es)above, also submit one copy of this foam within 30 days of
13b.Disinfection type:`f 1 r Amount:.'. c 5 completion of well construction to the county health department of the county
whereenostnleted.
FotmGW-] North CA10�> Dtm m aat a£Eavaaeaml QuaGry-
Divided of Water%moor= Wised 2 22 2016-