GW1--03099_Well Construction - GW1_20230428

Weer SuppW Well:
ocito!/ TO. it mom:. MU
.SLOT. IIIIERIIESE MATERML . .
. 0Agricitinual , ci0iPnblic. rt • .
a Geothermal(Reatinglaoling Supply) Mr,'U-Mendel Water Supply(single) rt. fr. tn. -
,3IndustrieVeommercial Oltelidellial Water SuPPIY(shlircd) 1-1ki01101 .. tii3. -•:-•=-,-`4,ste,--:=q-'•.<___ ....--4-- ilfiaszr.".—.`:" • •
1,Irrigation FROM TO MATERIAL I ILMPJACEMENTMEITIODit AMORNE
Non-Water SupplyWar .
1.4 b`nv:4tik *arts!.UR. •
r 3Monitoring DReco.vilY " tt. . - 1
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Injection Well: - • - . •
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a a . . .
• M. Avifer Rectorgo °Groundwater&Mediation
•i•-1.1"01.16= -40UrPACIratfiiiiii4151e)TAIR- 7.7,..1,6.,
3Aquifcr Sax:mend Recovery OSalinay Barrier FROM im MATERIAL i oust.aotaretrairraon---
M.Aquibx Test riStownwater Drainage ft. it.
3Experimental Teelmology OSubsidence Control G ft. a
.eothermal(Closed Loop). Dime . >ktaircnratavireargarionwaratircaiiiisw:FF-14-V-4.".tle ' "
To Doxiiitator.kudiuswayrxhArAnimire..10
Weather:no Rotiog(coogiii Renzi) MOther(eRiato under#21 Remarks) mtst
L/ a ft•
4.Date Well(s)Completed: i-ow---) Well mu, 75 fr• „5" fr.
5a.Well Location; 'f". 1 2 CO 16 e--,...--..,„6.."7--
,featf/la/ .. 30 f / 7 ft. ft.
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. Vseilityi0weerMatee .Fsoiliw UV glipptielauu) re rt. ' 1 l' ''"".•••,'t.:; itifZ
. )14(gaco4 cr.e.€It /fr 6 '4 4 i 'a °.Cr
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6 Q s f -,1. • 3 5 (.., yi/3,‘•pip.*iumfigateA,",..1...i-..-_,-.-t-iit..wp...ye-4741417-47,r6m-514,74-4.4.-.7-7-_-xs,...s, -. .,
Cetuust .Parealblacifiercion Na.(PIN) '. _ 'C'0142?/,.-)0 q UfliZ
5b.Latitude and longitude in degrees/minuteSiseconds or decimal degrees:
Orwell field.ma in/tangle saffron*
22.&Mardian:
. ‘.2 -0/7 7dra N 1/6 7 7 7 7 0 W
g . &ell- lYidif X)0.),3
Sigurirrified Well Contractor 1 Dale
6.blare)the ivel(s)1511Periniment or OTemporgy
By Aping this loft%'hereby ea*Um the irdll)Vat Astro)cottrinarttl a,accortkoce 7.Is this a repair to an existing vie* Oyes or DNo with LIA MAC 02C.0100 or Ltd SVC 01C.02110 Well Coennration Stotler*ced Mai a
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gait trorepotr,fil 1 orairnoonwrli cosuruciloi thilarthadon aid mini Merinos tote copyedit aro:rase beenprovirted to demi 1 owner:
repair leder•21 nolo*redion or on the bed edosfemn. •
21 Site diagram or additional well detallsr
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having these= You may use the back of this page to provide addhional well site derails or Well
construction,only 1 ow-1 is needed.Indicato TOTAL NUMBER dwells constructioadetaib.You may also attach additional pages if necessary.
drilled:
fijaHltudjammaga .
9.Total ivell depth below land surfaces )-.C 0 (ft.) 2o. Par All Wells; Submit this fonts within 90 days of completion of wall •
Orme:Viewer list al I&At fribffernt(azionild.30ICIP ad MO) construction to the following
10.Stade water lavat below top°fusing: 2ii (tt.) Division olWater Resources,.Information Proiesslug Unit
Omer lerel i t Ohm?carieg lit,"+"
1617 Moil SeMee Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 //4..4 (In.)
24b.For Medan Well In addition to screws the&into the address in 24a
32.Well constraciton method: abOvo,also submit one copy of this Rom within 30 days of completion of well Pactvy comnictiontothefounwint:
(s.sagermi. ssy.ratite.Olsen paub.eio.) ._
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Division of Water Resources,Underground Injection Cantu)]Program,
' • KIR WATER SUPPLY WELLS ONLY:
2636&lad Semite Ceuta;Raleigh,NC 27699:4636
13a.Yield(Rpm) if Method of 3` -- -72.47For Water SunDly&Infection Wells; In addition to sending the form to
the address(es)above,also submit one copy of this farm within 30 days of
13h.Didnfecdon type;_tail Amount: Cr) completion of well construction to the canny health department of the county
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- where constructed.
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PormGW-1 Rartz.ColutiouDeputorect arEakimmiainsiQuelity-Division of Water/Women Rovisod2-22-2016
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