GW1-2022-06749_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD(GW 1) For InternalUse 0aty:
1. 1I Coattactorinfor=don:
1r6 WATER 7A1V N
Well CotttraotorName FROM INMCRWfBox
9(46-�__G -qq E
f.
NO wan 1 {�
r
t?LtOM � DIAly� MA'rDRiAL
Comparyy Name fL �D ft. in.
fS.INIODECASMORTi1BlNG dared
2.Wen Constr edon Permitd: Fxobt TO D AIN= =C011sas I ,
Ltst all appttcabte weld rerutrrtction permits(d e.WC,Comfy,Slate,Vxfotee,err-) ft. ft. im
3.Well Use(checkwaH use): ft. ft. im
Watersupm weu: 7 s
Agricultural [3Muufcipai/Pttblio ft. t
Geothermal(Heaflugf Cooling Supply) g3lRes detttial Water Supply(single) R. R. in.
Industrial/Commerciel DResidentiai Water Supply(sbared)
Irn •on FROM I To- mnTEM" > CnMTxzMoD$Amtoittvr
Noa-Wa1er8W1y Well: R• W ft.
onitoring & R. 5
lineation Well:
ft. ft
AquiferRad arge DCuoundwaterRanediedon
PACK fff dImMel
AqudferStttrapeandRc=myy 13Salm Mt,
ttyBanlor mom 1 TO MATE �taese�Ne D
lA'cjquifer
Test E)StotmwaterDrainage ft. ft:
_VvdmentalTeeFmoloU DftsidenceConfml tb ft.
Geothermal(Closed Loop) DTiacer 20.D12II,LINGLOG atfaehadditionaldmets f
Geothermal ff Coo' Retum tJtlrar Isin=dcr#21 Remadm) 1 '2' TO Dt oN wlor aotthodc
et. ft.
4.Dab Wells)CompUftd: &Wen UN
5a.Weft Location: R. fqR P
facillWOOwnnerName FacilityM9(ifanlirable) ft. % 022
MystedAddrass.CiMmtd73p ft. ft. •.,i�;�,wyT1 F)PR A Syr
Cry Parcel Id®tificafimNo.(PII3)
6b.Latitude and longitude in degrees/minuteslseconds or decimal degrees:
(ifwali field,one lavlong is sttSeiem) 22.Cert'tRcationt
UL
_I :. c � ��
6.Ls(am)68well(s) ermanent or Temporary signanueofariwWauCaottad" Date
By signing h*farm.t hereby are that the w4s)ow(were)cmumreted In amrndmtee
7.Is this a repair to an ealsthrg well: JK. or ON. wtrh 15AIVCAC 02C Al00 orISANCAC 02C A200 Wen Congmctian Standards aaddwra
I/ift Is a repair,fill out Immm well wnsrruaton infm7wdon and explain the nmv ufdx capYo0direan hashan provldedto do weltmvner.
repairmrder#21 remar/sseetianaron the backafthisform.
23.Site diagtmmar addition's]well detailsc
S.fbr Ckoprobe/DPT or Closed-Loop Geothermal Wefts having the same You may use the back of this page to provide additional well site details or well
construction,only 1`W-1 h needed. Indicate TOTAL NUMBER of wells construction deML.Yon may also aft&additional pages if necessary.
drilled: � � W47'RV['1T�1V5
9-Total well depth below land saefacet Cxu� (f:) 24a.FEU Wells: Subunit this form within 30 days of completion of well
Formultiple webs!!stall depths ifd nt{won pie-3Qa/n200�oad2Qt009 construction to JbUowi*
10.Static water level below top of casitV. T �� (fL) Division of Water Resources,Wormation Procesain IIni4
1f„�level is above oaring,use'l-' 1611 Mail Service Center,Raleigh,NC 27699-1617
il.Borehole diameter. L, (in) 24b.Farlafection We11st In addition to sending the form to the address in 24s.
12.Wen construction method: above,also submit out copy of this form within 30 days of completion of well
fie•auger.ems.ed k dhvapnsk eta) conslmctitn to file fioAowing
FOR WATER SUPPLY WELLS ONLY: Dlvlslon of WeterRemo>�s.Vnderamund kdeeffen Cnnt.+ol ltcoSt�n,,
1636Ma113erv�Ceni�r.Itale9gL,NC�769A1G36
13a.Yield(gpm) Method of t 24c.For Water 3ntmiv&�.Tt In addition tD sending the form to
L I� the address above, also abo also Isabmit one copy of this form widdu 30 days of
13b.DisinfecRon type: / AmoDat; completion consttnchon to the county health department of the county
FormGW-1 North CamfimDepmmm-toff-*o=eutel
Q=hLy-DmumofWaW Revised2 2L20f6