GW1-2022-09993_Well Construction - GW1_20221104

MILL LONSTRUCTION RECORD (GW1) For Liternal -nal Use�dy:
1.Well Contractor Information: J j/
Well Coatrav�N me v t �G V�4 "'re✓/1 .14WATER7AN&4'>'„'�.y -sty. ,.
char mom .F?W&9:?i:..v�.'ii-r
. TO DE4CBIIRTA
iL IL
NC Well Coalteador r.rta.atinaNumber fL fL
/ t '16±0L17[ER:CASING- FROM TO/ form—i"Dr leItMeuETrdEiRi elli ORTH'II,INCEWERES S
CompaayName sr a"'EE6rtAblTeE rR+7?A#;Ly fL fL In.
2.Well COnanvCtian Permit 4: p -C16.'INNER'CASITYG ORIUJBN'G.'eutheivTal elmed-l6a 6
i*_sG?:,n::'�'Y.+r,Gi;9'J.�`J'� J %Q FRobt - 70 MIErER THICE4Vns afATER7Af,
Ltst rag applicable sve(leaalmedon perms[s(Le.U1C County, DI Srak,Parlance rfeJ R R In.
3.Well UsJ(checkwell use): fL R Im
Water Supply Well: '?17:SGREFNe;£;;'r�!yRt':'::(u5i.Sic?Y�".r':n.C23i•N�..t�iru`.;ft'¢cr '
.. Agricultwal moot To n untErER L aarslze THICKNESS�MunicipaVPublie O R R In. nm
... Geothermal(Heating(Cooling Supply) E)R€sidendal Water Supply(single)
LedustidaVCommeroial R R It.Water Supply(shared)
Imi ation =38 CR0111'1.efh1B,C+F:iiai:�',?ls.
NOIl-Wate Supply Well: mom (t 70 R MATERIAL FMPWCFS@tr ERIOD@AMOUNS
Monitoring [)Recovery 'a
Injection Well: R R
.. Aquifer Recharge 00roundwaterRemeiliation R R
Aquifer storage and Recovery Salinity Barrier !' ' i--Guble>�x:+e`!':'R:iv^�J1ti^,.„�jt5yy,:p;.;-nA,S/.��.
FROM i0 MATERIAL EMPLAfSA NTKEMOD
_ AquifaT t �}Slormwaty Damage R tL
_. Expervnertal Technology OSubiddence Control fL fL —
Geothermal(Closed Loop) ra-jTTacer
LI .10.1)RN:LINC LOG ath2b'iEditidnali6ei•.l4jrfieceaid"
Geadhermei(Heating/Cooling Cooling Return Other explain under 021 Renmubu ntoMTO
.. DFStatmTrON inter aaNaea,,,rtgmek
R . V IL ata.ate
4.Date Wells)Completed: ')—2Z' WeLL 7D# AR Ill. -e d(-/r #
Sa.Well LoFation: _. : .d 1 _
t g " Wh IA i
F_4�c0Ry�/pn�aer�Neme Facility My(d'appBrable) Q 116 B.
e r:6 natwad,rs;o ems' < l'cis .5.1 11 (�til)" n ~ R 75
a. Z e.
ib,andZ G
m e) 3 Y s m
-1
County I .Pamdldenti6eatio¢No.SIN) ... l.W,y.R,. ` "-
5b.iatitude and longitude lndegrees/minutes/seconds or decimal degrees:
(ifwell field,one Izdlong 6 suffieieat)
t i e 22.Certification:
L37N_ W
_zz
6.Nam)the weLL(s)�mmaeat or DTemponry Si oCCrrtified. ell Coahador Dale
7.Is this a II By rignNg thts fame I AerebY cwrH din[the sveU(s)War iiwe)mmaxckd In accordance
aepairtoanerisdugweLL: []Yes or IEDNo srOh ISANCACO2C.010oor15ANCACO2C.020o WdlConr
lfthltfro rePalrfidout.6sewnsvelleom"cdon Womadon anderplata the nature othe cWvflhfrrecordh=Eeen ounlort Sfmdardr andthata
repalranderR2lremarlamctionoranthebackofehtsform. f proHdrdfo lAe xaltmrner.
23.Site diagram or additional well details-
S.For GeoprobeMPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional Well site details or well
construction,Only OW-f is needed. Indicate TOTALNUMBERofwells construction details. You may also anarh additional pages if necessary.drilled:
,n
9.Taml we depth belowlead surface: SUBMITTAL INSTRUCTIONS_ „/ 7� (fL)
Fnmulriple hve!!rlGtalldepOu lfd/fferent(ermnple-3®700'andl 0 24e.For All Wells: Submit this form within 30�f 0) days of completion of well
�/�,�t,,�� `` construction to the following:
10.Static water level below top of casing:_ /J1fAit.' t f, (fL)
lfwaterineltr above earn$are'+^ Division of Water Resources,IDformetioa Processing Uait,
1617 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole diemeter.�_((D)
tt 24b.For Injection Wells: In addition to sending the form to the address In 24a
12.Well comitruction method: ('(,�'t)Q.✓�I above,also submit can copy of this form within 30 days of completion of well
(Le.auga.mtary,eabSe,ducct push,etc) construction to the-following:
FOR WATER SUPPLY WELIZ ONLY: Division of Water Resources,Underground Iolection.Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm)_ 7>f' Method of test: ' rL 24c.For Water S naly&Infection Wells: In addition to sending the form to
13b.D151Iltection type: G C the addrese(es) abovS also submit can copy of this form within 30 days of
Amount: Completion of well construction to the county health department of the county
where constructed
Farm GW-1 North Carolina Depaumem ofEnvironmenmt Quality-Division of Water Resources
Revised 2-27 3016