GW1-2022-10788_Well Construction - GW1_20221208

WELL CONSTRUCTION RECORD For Internal Use ch�ly
1.Well Contractor IIntoa omdan:
14�A77t
I '
Well Conlcuhx Name FROM To BOEW9'x N
& i
C Well CRHUSeW Cenific&Wn Numbcx
MGM TG DGA�FAM, EHdCCLRE°c T4f�JA
CorapaayNun Al ! ;fo
2,Wtu Cowsuction Permit tt: � t FROM I To I nL4 Twe-sNm naAdExrAd.
Lirr add c*p1kabk war/l eonrd'etcoon psrrma('i.e.UIC,Ca"y,Stale.Varlamv,ex)
3.Well Uee(cbmh wen rose): R fL to
Water Sup*Well: -
gRUM TO DYAfbSPTt;St hG Q(Styli T�T� �„l9 ei UIL
cultural bmlmicipaLTublic ry n°
amal(H�Sl��g Supply) esidentiRl Water Supply(single)
hubmiat/Commetscial Residential Water supply(sherd) -----
I41a t7r1 mom f0 KAT$RIAL UPPLAC1*.ilU7r 3Yil� Wfi A A6tUETAT
AIw.Water.Saspply Well: E8. fL
oninnt Recovery
tr. fL
Aquifer Recharge DGrotmdwarer Remedislscs
Aquifer StonW and Recovery Dsihnity Barrier FWM TO T. MAT AL �MPLAY�EI NT NF t7lUD
Atluifw lest Stonnwate~Drainage iti ti
Ltxprtimental Technology OSubsidenm control
(Cloeed Loop) D'fracer AkIt9Sfl1D.Y3F3G LOG(RacB►edalueat Alt MMVI - -
QeothetmaP eating/Cepoliag Return) ether(explain tpadcr 021 Re:mmios FAUhe Ta '-'T DEKIMMM meter nods eoavrcals cis -
4.Date Wawa)
Zomplatedt W a&i:13D4 .. _ R ft -
--__
13w ATame `F�acektyID#(st'appliwablej -�� �=,777 •' 7=737 �� _
\ 6
Pkysiml Ad dram City,and gip 1L as; r iA
.ttl.
tv141. �
�� _•e '•__ t�.5�37,��ram'' °
'74-
9 P,9rce31e ation NO.(P"
Sb.Latitude and lonetude in degreWminutealseconds or decimal degrea : -----
(ifweU fitsld.erne lat/long i9 nr�cieat) 22.Certllleatione
04
i ofCxttifirxl Well Coaf:actar i
6.Is(are)ilea rovetll(a)�Pert�tettt or '1'xuatpOrary g°'0e""
Z-1-10-
By si&—g this form.1 hereby certify that the wr11(s)wtts(tc )—AiAted in accondarue
7.L tlzli a reprtir to ssu existktg well: yes. or ONG with 15.4 AVAC 02C.0100 or 1 S.t NCAC.OX.0200 Well Cowtntction Standards and that a
If Lois is a nwair,ft11 out kw m cell croasrrumon ofon woon and explain the WA"of the cgpy of this record has been provided to the well ater.
repair wdtvr 021 ttfatgudrs secticw or on tk back of this form. $3:'Sits dkgrteDt or ndditl0rea3 well t0e1al1S:
8.For Geoprrobef)DP-1 or Cloned-)mop Qwtheiraml WdIs 141ving the same, you may use the back of this page to provide additional well,site details--;pi:'
"well
corsstrtuction;only 1 OW-1 is needed. Iudicate TOTAL NUMBER of wells construction details. you may also attach additicmal pages if necessm
dfille ° — SDTl31Yli7")r�i.I:VS�1tHiC ®I115
9.Total erell dpth below l=d surdaee: ,;1 m`�^� _ (tt) 24a. Fpr AD Welts:-Submit this form within 34co:.npldign..vf well
For mddl de wellm.ilrt art depots irdiprew(example-3( 200.�and 2 10Dn
�... r constmi, as to the fo lowing
�tr 1
fl4.$tr�3s. >st icwel)►elaer topr of twine:
dam) Z<3ivlsboq®f Water Ylecourc ,Inforetrstlasa II?roc�sing Urelt;_ .'.
!�r'xater t¢awl d,aborau awstng stye"+��� itr171bYatl 5ervlce Contra,�lelgls,?®iC 27t�1--fl61?
24b P©r dntec Wells' In addition to sending the.form to the r,eldrt=ss is 14p4
1 above,also submit`one cauyOf t] s orm wrthrtt lUiB�iys of oompltihon�f well
12.Well.conatracdon od's cgastruc on to the_foll®wing:
.(Le.•ap$es, .mbte:ditgctpu9h'Ec).,�.___. -
_-----�---- 19aflsion.6fWeter.ltnburces,.Ylndertp arntlla�ccdosrCorttrall+rosgrane;
FOR WA7Hf SUPFLY VMLLS ONLY:
:.. 1636 Msl1 Service Canter, NC 27 -1536
130.Yleld Ma thbd bf tixii:� �� lac for.Wa r 5arors)v&lrul�tl D4telit:. In addition o.&adirg the form to'
the kddreos(es) above, also submit I,one copy of this foram within 34 days of
13b )8t tect3oney+pe: Aaareriota completion of well construction to�e county heft depaitment of the`cotmty
-�--a-- where constructed, .
Form UW-1 Nm1h Catlin Dcpartrnent of Environmental Quality-Diviaion of Water litao'usces P.evbed 2-2::-2015,