GW1-2022-09069_Well Construction - GW1_20220923

Jan. 29. 2018 10:58AM Env. Health . No. 6711 K 1
WELL CONSTRUCTION RECORD(GW-1 For Internal Use Only:
1.W 1 Cmttacto IDfotTaati j
WdlContrttetarName FROM TO DFSL7m'[7n F -- —
NiOR s tt ! G ISM
R R.
NC Well Codtnc or Certification Number IS.01k111C CXSLYU: dlGmoll[`'-i8 ry :UItL7REll 6_ Ede", ;.rl`a" "
FROM TO DIAMErBR THIMESS fill
CaatpaagAt to � � VC-
-ANNERGASIN( OEGCFJDiMG? thidn,at;diaet!fir' �.t�r: T —
2.Well Construction Permit ll: FROM I TO I ofAMRYRR I Inuma" SLTEWAI
Liar all applicable wall totuwerion permert(ta.UIC.Corry,Sa%Yarfonce,etr.J R. tt. lo.
3.Well Use(aheckmll use): n. fr. to
Watersapptyi'ire11: _-..__:->u•-=.=: _. :...-.._.............._:..------.....___.
FRO,H To DIAMEreft SL MIC MATERDtL
_Agrkulpasl "l/pabllc 0 R. rt �.
Geothermal(Reat4VICooling Supply) ldeatial Watts supply(single) R.
_Indu*WCommcreial [3Resideatial Water Supply(shared) _y�GROUT_:_z0-1���,-
Irti lion NMI TO MA AL IMLACrMMMEMOD&A510l
iVon-Water Supply Well.• ft. IL
Monitoring ❑Recovery R. IL
7nJutionwell: fR
Aquiferftechergo OGroundwaterRemediation 19C kbrDlGR;iVBGY.Y Fii"'tr6iti►' _-x=:_ - � "''" 'T
AquifcrStoragc and Recovery [)Salinityllaaier TMI TO MATERIAL t.MPLMXMKtrMVMD�.-
_AquiferTest -dStamwaler Drainage R• ft
Experimental Technology dSubsidence Control m ft.
Geothermal(Closed Laop).- Tracer s10. f:ISit:a"ed-dlttoiteiyl i;—trlfiiK ari =-
_Geothermal(HeatinpJCool Ing ReturO Outer lain UDder#2l ltemefks FROM TO WCRIPtION olar,h wnYevek.�: do
�r ap ft. ?G ft.
4.Date Wells)Completed:! y Well IDa D ft n ell�.,.��->•r{_
5a.Well Location: l
a tt t2 '/ a n er� 5 c LEE,.
Faa7 Owner Name PacdityIDO(ifnpptire b) 2 n.
Pltysi.d Xddamt,City,aid Tip O {'t1T.C;rs3 x^1 fit, .., Ll r ll
Coaary Pareellden"edidallo.(PIN)
Sh.Latitude and longitude in degreeslminuteslseconds or decimal degrees:
(3alS field.
�atauton$is suffideno C6rti
G%D Iv C' tarp w
� � 22. fteatlan:
6.11(are)lhe IveiRS)IOPlermonent or [Temporary Sigumm oteenifiedWellConoacror Dato
� By algmng thus faun I6emby aer*rho the wd/l(r)tray(Irem)twi avared m aacmdoace
7.1s ilds a repast to qD eshfing weft: OYes or d�`a with 1SAIVCAC 01C.0100 or lJA AUC 01C.0100 Well Coarnratton SoK*tdr and that a
t(rlds et a rspah;JIR ors lnowe wdt emurn,uioa rnfarDiOroin mrd etplarn the ni/(nM attic caPy oJrhm nuord snot DseuprotYdMro Ura wall owner.
repair umfor e11 mawAr ae wn or on the boctofrMrlorm
23.Site diagram or additional well details:
8.For GeoprobNDPT or Closed-Loop Geothera l Wells having the some You may use tho back of this page to provide additional well site details or well
construction,only l GW l is needed.Indicate TOTAL NUMBER of wells ConShuction details.You may also attach additional pages if necessary.
•. drilled: tr'IIl)MITTAL Ity5TR11C7')<QlV3 '
9.Total well depth below land surface: h) 24a. For All Welk: Submit('his form within 30 days of completion of well
bbrmnlrrplexelkbstajf dgdaiifdJjacto(emmpre.38100•ond2 100') conauctionto the follovill
10.Static water level below top of casing: C/ __ (a) Division of Water Resources,Information Processing Unit;
ffwarerlords fraboveau tE use"+" 1617 Mail Ser4lci Center,Raleigh,NC 27699-1617
11,Borelmle diameter. V1j (UI.) 24b.For inlectlon Wells: In addition to scn&ig the fans to the address in 24a
(Q� r,,q above,also submit one copy of this fol within 30 days of completion of Well
12.Wellrnnsltnetianmethod: /\��r1�{ rgnsWctiontodutouow;ng:
(--augw.roloy.cabir,dirt el pwb,do.)
i
FOR WATER SUPPLY HELLS ONLY: DivWm of Water Resources,Underground Injection Control Program,
1636 Mail Setviela Center,Raleigh,NC 7.7699-106
s
13a.Yield(gpm) t7 Method of test . 24c.For Water Sunnty&Injection Wells: In addition to sending the form to
0
the address(es)above, also submit one copy of this torn within 30 days of
13L Disinfeedon type: �Jl Amount: completion of well construction to the county stealth department of the county
where eonsltucted.
F=GW-1 NortRCammmDerwtmeet dtEaairoameatal Qmlily-Division of Water Rwoarw ReWsod 2-22-2016'