GW1-2022-08586_Well Construction - GW1_20220826

Jan. 29. 2018 10:58AM Env. Heal th No- 6711 P: 1
MAE
WELL CONSTRUCTION RECORD(0 1� Forintelnal Use Only: ,
1.W 1 Cootratto ILfaPIIlafla ` / f�' '
WdlConnact"Namc MrA TO DFSCRIPMN
ft. lad ft.. .7
- ft. ft.
NC Well Conoac or Cenincetion Number (6_p1IjTEtC C�SLYG:[o tmidtfea9e3:ty 1[s:UIt1 iNEIt fa i "the et!
FROM TO DGMMR THEMEss MATERIAL
Cocdpaa e
_ p ,•,Jf 1 s:16e11VNF,R.CA51X(�OII'TIrA1N.Cw:...�tl�v'n�of:rlofed:too'�.u++.�ra.T.-�•�---�.•-=r
2.Well Construction permit#: ( FROM TO DIAMCrRIt TIgCI a" HATERUL
l frt atl applicable well cmutnretionperrnrts n e.AIC.Couoo"Stare,Y dance,ere.) fi• n• In.
3.Well Use(ebeekwell use): n.
V' applyl all- FROM I DIAMEM I SLOTS= I TLICKNESS I MATFx7AL
_Agricultural QMunicipalftblic ID ft. It. in.
Geadrermal(Heating/Cooling Supply) }Residential Water Supply(sftw) ft. ft
_Indus tsWCommcrcial [)Residential Water Supply(shared) _
"18OAOU�:�=-=— -� :: •�--x - _......::.,�.zW
_irrigation - axon) TO� MAMMAL MIPLACEMENI'MEfHOD&AMOUNT
Yon-Water SupplyWoIl
Monitoring }Recovery R It.
tion Injec Well:
._
h. A.
Aquifer Recharge OGrouadwaterRemediation
:39:,SANDlG1tAVB&PdC Fsi_Rwlile '-=_•:.'x•� _$tarageandRccwery 0SAlinity$arrier FRO]l TO IMMERIA1, EMPrACFMEN bWMODJAquifcr
AquiferTest oSturrnvmterDrainageExperimental Technology Subsidence Control ILGeothe—mud(Closed Loop)- OTracerGeathrnnal(Heating/Coolini Return Other ex lain under#21 Remarks FROM To DESCAUFFIDN(color.lucdncswwWmck .. to Am etc._)
rr. f: C/o y •
4.Date Well(s)Completed: )Well MN
5a_Well Location: / l o�OS 1G �/ow• P
t
Fivitylow H2ate / FaclintylDit(if/iipy/ti�ca/btn (/,,/ R o
c/�1 i rS�'//�iu c•Cis Q'- t(/,V Oy 6, h it., lG �
Physical Ad&sass,City,Add Zip
S f9r Milm
County Pascal Identiscatina No(PIN)
56.Latitude and longitude in degrees/miatites/seconds or decimal degrees 'l
(ifwall Held.one lar/lang is sufficient) 22.Certification:
O 7�6d NFL?, dSooW /�' �?�
t A
6.Is(are)Ibetvell(s)ioPermanent or QTemporflry Sigiumn o9eenifiedWellContractor Date
By eig,.ing tldr jarh4 I hereby evlh Char the well(s)tray("PS)eournuered dl accordance
7.Is this a repale to an existing well: ❑Yn or QNo with 15AMAC 02C.0100 or IJA NO►C 02C.0200 Well Cominfedon Slarrrlordt and that a
I/rlds is a rlpak fi,7 otalnoun wdi calcurue ieh lnfarmadon miderplani the nature of the copy ofrhls recofti as beauproilded re the well owner.
r`pair uadera7l reniaAr weft or on the backajrhtrform.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back-of this page to provide addit oral iH' '%t4 Mails oFK"VW-i r
construction;only l GW-1 is needed.Indicate TOTAL,NUMBHR of wells constmctiondetoils.You may also attach additional pages if necessary. l�
drilled: AUG C 2022
SUIIiMITTAL INSTR:IJC7'IONS J,7 C
9.Total ttelldepth belotvland surface:_ � > A) 24a. For All Wells: Submit this form witha4;Q*Y,�t4fs pin
>�fu0 tXe
Formalaplewerrsfirt all dep&ifdiffaew(winple.3QZ00'andZ@10U) construction to the following: rtt�. u�'#
- � J..�Z•c'9t�'u
10.Static water level below top of casing: (10 Division of Water Resources,Information Processing Unit
ljwarer level rsabmacming use+" 16171fail Sorvlco Cehter,(Raleigh,NC 27699-1617
11.Borehole diameter.__`�"(In.) 24b.For Injection Wells: In addition to sending die fannto the address in 24a
12.Well construction method: r�(
above,also submit one copy of this form vA[hin.30 days of completion of well
/��� "
CLc.auger•rotary,cable,6xil punk cto.) construction to die following.
Division of Water Reinarceg,Underground lnjeedon Control Program,
FOR WATER SUPPLY WELLS ONLY- 1636112i1 Service Centel•,Raieigb,NC 27699 IL06
13a.Yield wpm) 7 Method of tesr C 24c.For Water Supply&Inleettan Wells: In addition to sending the form to
the address(es)above, also submit one copy of this form within 30 days of
13b.Disinfection type: �!l Amount: � C� completion'of well construction to the county health department of the county
where constructed.
FarmGW--I NoNsCaml;nnDeputmedt afEm unaineaml Quality-Division of Wat"Rcsotmes Rcvisod2-22-2016'