GW1-2022-10639_Well Construction - GW1_20221128

Jan. 29. 2018 10-:58AM Env. Health No. 6.111 F: 1
WELL CONSTRUCTION RECORD(gM I Forintemel Use Only:
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\Miter Supply\L•ell:
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- AquiferRecttsrge OGmundwaterRemediation
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FxperimentelTechnology aSubsidenceContml ILiG
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J.Date wells)Completed: O, d-�a WA MN
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Fsa7itylOtvnettJame FtpYyrD#(ifnp➢ueable) & n• ; -
Phyaieot Addeerr,City,oad Zip � — � � , - - •
Carry Pueelldentr&euiaaKoo(PII3)
5b.Latitude and longitude In degreeslminuted/secoudi or dedimil degrees: I' 1
(ir-waall Hold.aote�hditiissuffid tit) Q L/�73 O 22.Cerlilhation: ,V a- f
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6.I8(are)16eweTIM19'ermeneut or CITemporAT Stgrnt�eo ertiHedWeRConase-ror Date
By t,@uag Brit farh I here iy car*dim rhe.r dffik)uat{%ere)M,ttnittUd M Gewidams
- 7.rs fhis a repair to a0 C96ting well: QYea or 13No _ - w;,6 lSdNCAC OICA(OD or 13A slC,tC 01C.0100 WeBConunrwloa Sfm,do►dr mid that a
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23.Site dtagrem or addifooas[well details:
$.For GeoprobeMFT or Closed•Loop Geothermal Wells having the sema You mq tsv ft back of this page to provide additional well site details or Weil
eomshuetion,onlylGWlisneeded.bdiattoTOTAl.NUMMofvxh eonstadiondelails.Youmayalsoettechada enslpags;fneecs=y.
ddUed SIMM TTaLItVSTRIIt:TIOIdS,
9.Total well depth below .)and surfacer (D.) 249.For All Wells: Submit this form within 30 days of completion of well
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• 10.SfatictrateT level htloty topotcaf;Og: �� _(t+-) DhriatmtofRrater If urees.fnformatton t'roeesatug Unte: "
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IL Borehole diatmcfer: OIL) // 7AL For inl` eettoon Yens In additlan to sCadu:g the 6mmw the mW=in 24a
t 12.Well construction method: j)�I 1 ( abom also submit one copy of ft fm within 30 days of completion of,well
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FOR WATER SUPPLY WELLS ONLY: Division atWater Resenroes,Uadeteround In;eedoa ConRcl FroEram.
1636 Nail Service Ccntei•�BaIeigly NC 276991636
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132.Yield(gPan) Method of ref C . I !• 24e.For water Supply&Ink¢tton Wells: In addition to sending the form to
flu eddress(w)above;also submit one copy of this faun within 30 days of
136 Disinfection type; Amount: Car completion of well construction to.rho county health depagment of the county
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