GW1-2022-06712_Well Construction - GW1_20220712

Jan. 29. 2018 10:58W Env, Health ,. No. 6711 P. 1
WELL CONSTRUCTION RECORD(GW_j)� Fpr Internet Use Only: ,
Coniraeto IDformatio : `
h2ir'3VAT:99220140,•._-_�.:x;=';�'.�'i=.�.�•'.=_„+.,:p+,:::m r}^,cu:.-.:::___._._.._-._.
WenContraetarName FROM TO DESCRIPTION
ya n Yes ° .�,
NC Well Coaoac or Certification Number ' tLVl M 6-"h3itblb:ai
�� �� FROM TO DIAMETER° IA IMFSs MATERL
R, R, 6yia (lam
Coronas a
- :1NNER!C NGt OlYTUDTAIr°` 't RIUYt:rIpfEa:Iba �svinwTr -t==:
2.Well Construction permit#: 7 f moll To 01AMMA TMCXNEU su7zRVAL
Lisra/l applicable welltartars bon pemdu(i e.UIC,Caunry,Staten Yar once,ere.) h• ft. la'
3.Well Use(cheek well rise): n. ff. In.
Water Supply Well: FROM To I DUMEUA.I sLOTSIM I TUICKNT3s A MATERIAL
Agricultural QMunicipsl/Pnblic 0 ft. R.
Geothermal(Reating/Cooling Supply) Residential Water Supply(single) (L R in,;
_Indushiel/Commcvaial [31tesideatal Water Supply(shared) _y8 ax0>IT :: -•°gay es . � = -_ -- --.
_Irrigation FROM TO MATERIAL MPLACEMENT. LTROD&AMOUNT
N
on -SupplyWall: n. Lt. l` r �tU
oring ❑Recovery R. R. _ —
n Well: a R
erRechargc 00ruundwaterRemediation
StorageandRecovery CISalinityHarrier -TR0111YD/I TO frP,YCKIATERAL EMP(A6CMWM DcrTcst riStorowalerDrainage n frimental Technology Subsidence Controlermal(Closed Loop) QTraeerermal(RealingiCnolingRelum Other(explain under#21 Remarks FRabs To DrscnlrrroN color.findrterr,ralYmck foe ate
4.Date Well(s)Completed:_well D# y�(/ h 7 ft. 6's
52.Well Location: 7y 1
� / ? �
FacililVOwaacName Facility Iris(tfcpplimbla) IL n.
), 140 Grr,&^U-,;,W d/ /nr 2' Ifs//�/ .uG It. ft.
physical Addror:,City,ad Zip It. if.
_...-.-��_
OF
Callow pmeel Idemi6catian No.(PIN)
56.Latitude and lohgltude in degreesimiatttes/seconds or decimal degrees: ^�
(irwelldald.one latnan&sufliciad) 22;CeertiGeation:
1S. 1�a 3 N` l. c/3 30? 7 W
Permanent or Temporary 9igomne a eni6cG� d Well Contractor D810
6.Ia(arC)the 1yell(s)
Ey signing this form•I hereby eerab that the urell(s)was(i tm)comhucred at pacordaaca
7.Is ibis it repair to an existing Weil: E)Yes or MNo with BrANCAC 62C.0100 ar IM XCAC 02C.0200 Wel!Co urntetma Slanklarotr and that a
(/this isarepak f ll ors hiewt well teArnacrian hforseation and etplarn thenattme of the eopyofrhis retardhas been prowdghro the ivell owrer,
- - - repair antler N7/remark ttctlan or on the baekof rhtsforn,. _ __ '
23.Site diagr'ana or additions(well details: _
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use fire back of this page to provide additional ws11 site details or well
construction,only l GW 1 is needed. Indicate TOTAL NUMBER ofwalls construction details.You may also attach additions►pages ifnecessary.
drilled: SUBNHTTAL INSTRCICT1 M
9,Total well depth below land surface: L b/S 00 24a, For All Wells: Submit this form within 30 days of completion of well
For maluplevelk1&r all depths ifdfbcm(anwle.3@2M'wd2@100') construction to the following:
10.Static water level below top of casing: Gp 00 Division of Water Resources,InformRilon Processiug Unit
/flvarerletelIsabmecmiag tore"+" 1617 Mail Service Center,Raleigh,NC 2709-1617
1L Borehole diameter: 10�--". "(in.) 24L For Inleellon Wells: In addition to sending the fann4o the address in 24a
above,also submit one copy of this;font within 30 days of completion of well
12.Well construction method: construction to dre following:
(ix,organ ralary,cable,t5tecl path,eta.) ,
Division of Water Resources'lUhdtrgeouud Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
t
13a.Yield(gptn) Method of test: r C 24e.For Water Simply&Ieleciton Wells: In addition to sending the form to
� the address(ea)-above, also submit,one copy of this form Within 30 days of
13b.Disinfection type: �A Amount:!-� CG/?� completion of well construction to the county lualth department of the county
where constructed, j
FarmGW-1 North C=M=Dq=w*at afEavituamatal Quality-Divlsian of Water Rrsoareas ReWsed 2-22-2016'