GW1-2023-02520_Well Construction - GW1_20230406

WELL CONSTRUCTION ItEC4RI)(GVV-1) r aural Use axtty, _ -
1,'WellC9101rmstorinfornwtiore
cow Z'R
—� i'603t 7U pF�tIIPriQ?t '
Well Cot,ir oor 7 me
� �-A - -
IsIC Well Con+Stor Cc ificatiazi NomIscr -- -
au�ttreasmll= f�;a»ztia;�ar��x:zu�� . ,�nl� '•� .
61�GiYI p e r t PIA
a u - p _ M.
te.
Company 13ame _
2.iVVell Cottstx nctioA�etarEt#, Z t To I UPOSU i I T1110EMM I hsarrx AL
L7stsii t pllcoble,m8 cvnsuzraVonpernrls(ce the-cotes; ajar arxe etc) ft'3. -
ft„ it, itt.
We1i Use(eltech-Well use)• _
-wAter S4U,F,,F�,i WdL.
""'!'' rFRM1 'rQ-. a D7_ 31E-i'FS SLOiSF7.E 'IHK'I.l`PSS 3fA7ERLiL
fi8tiott]ttl�ai �I►3�io+ipa+l/l'ublio t3, ft, _is __ - _
t cothmmal(HoatinglCoolmgSupply) MidextialRe WawSupply(sm-de) ft, tt to
IudttstrialJercial sift Water Supply(shared)
f�
TO II1 .At'E31E1`YI 1tiEIS4D&A'NOTit1Nora-Water Sup*V ig:mottitQiing ! . ft - n-
Itljectionwd — — . - - --
AquiferReebar'ge Rettediation -- -
_•ASGS��1�7A1�'R,1.'1~'.�[.�'ACK a hle. _ :r� ', . .
Aquifer Storage and Resov,'r 0Saliuity Bturicr >F1eo o tt X-ERrai- tieLuEnttiar htsruao
AquiferTest �Stotmtratzr�i a (L R
F-Ved-mental Technology nsubsidi mw Uol�l !z t5
oeothettnal(Ciowd loop) ElTrac� 20)TRILI3�i�'X43t
oUlzarmal tine/ R Oda 1ai�under R21 Rrks) ratr�r TWO - _- npseRrPi7t lain tztssiilrrodtr sfueta
r�;'(+
4.Aate;V€it(�)t AM- pleted; 3 - 3 S'1'e11 ID#- �' t2 � D C -
aa.Wiie[I'l�osae3on: b
ft, tt
Fdciliry/9w4rrlTams Fccdrtyli IL
{ifappli-ble) ?,
Physical Addrcsa,City,and Zip � TS A `' 2�
�L 7tII47ARIM - -
�ci
-- — dig u01777 �
ca-ty 1'ascelIdcaAi6c+tivui�o(Ply -�f`'$
ftLatitude and Iongib-ideindegreWntrulesftem dsordccka i ftrew, - - - - -
(ifwdl field,one latlloim,is sufftclentt 22,CcKtAcatiow
61 Is(are)the Wells) Permaraeg►t or Mempota r-Y
6i� eofCertifu 4yeltCertuacwr � Date
By sf&mng ties f9rrn,I hereby catty thou the WCH(s)Iras(Isere)eongrucretl in amrdance
7.b tl>Tts of repair t9 an cx[sft wcU. Dyes or No with Ifil e4tdt'P?C.tllOt)or l5A NC.4C P1C.�Ot)tPe11 Constn+cfion Standards mrd that a
{('this is a repair,Ertl out krtoxat mll aortsmrertatl itrform tunnand csplain die rwture vfthe �FY nf'thla recordhasbecn p�Iidetl to th-well mltler.
rep+rirutrdcr 31 rcnrslrkssesdmrtnmrlhcbacl oflhisfoml 23 Site diugramoraddit[ona1welldetails.
$,For t;copxv[�s/BgA or t�Ossd-Loop tGeotht t�ruti Wells having the same You may use the back of this page to Qrovido sdditional%veil sits details or wall
mnsilnotioD,only 1 QW-1 is ue d€d. Indicate TOTAL MAIM of wells etion de tails. You may also attach addit a ai pages ifat scary,
drilled: MMMITT AT.1N,tMUCT[UNS
9,Fetal well.depth below land surface; 00 24A. For All LVcils• Subunit this form within 30 days of completion of iNell
For muldpleWHSUst all depOw f4fferew&MMP70-3&'00`'o2@1M convtiT - ontol3_-011owing'
10,Stntiewaterlevel below top of casioS;�. -__ � (M) Pa'wisioat of Watax•l+;+esoealoes,,Tatfortnataorr Processing[htit,
Jf wwarleml is above casing.use"+" 1617 Mail Service Cextter,Weigh,NC 276991617
11,Borehole diaracteu: (in.) 24b,For Injection 1Veils; In addition to sm ttg the form to 4te address in 24a
�J above,also submit ono copy of this form�vittt�u 30 days of completion of-YOU
14 Welt construction xwthod:�� �i�'l/�;� Construction totho following:
(Lo.auge,rotary-,ceblc,ditectpwb,ctc.)
_ _ --- 13ie7519A of Watfet•Beso�I7xxdergnnund ItnjOStion Control l'toar;un,
I++S7R W:41M a^[Il'PIY►tiT LLS 9ny-- - 1636 AM Servlea+enter,Wei*NC 276991636
1
13i.Yrdd ftyp) Jo-a Xkthod ofte-st; _ 24r-For'Wnter'litmnir&injection Wells; In addition to Sending The fern to
'^ - gw addresses)atbuvr,also submit one copy of this form witbin 30 days of
co'Pwou of maeousumatiau to ie dounty health department of the county
- -_--- -- _ Kitae consttrtcicd,
I
. I ,