GW1--05828_Well Construction - GW1_20241001

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WELL CONSTRUCTION RECO (GW-].l For Internal Use Only:
1.Well Co tracterlid ado • ` I
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�lJ`dh�/�.� • 16 WATER EOM•
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Well CsatrrAor Naas FROM TO I DLICIUNTIOH
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NC Well Coaesaelor Certification Number •
ft ft.
15.OUTER CASI1 (fir ndtl-cased weIb OR LINER(If up liuble)
t J 3ro -e v s PROM TO _ DIAM1TIR THIam= MATERIAL
Compsay N.
I
la I
If.INNER SIN°OR TUBING(Enlrermd dad-le
2.Well CeptraedeR Permit N. PR I- a C) f••i O�C�O TRoM To. •DIAMETER �1
LW all appllasbk wall earrshrcMoa s e / rooms, MATERIALaaw+l (1 [fJ�Cesarry Sere,{'.r#sncS seeJ -f—! 11isaR s V 4T/nen_ ,VL-•�
3.Well Use(check well use): R J
Water Supply Well: 17.3CREIN
• °Agricultural OMunicipal/Public _FROM I_To _ I DGMETEIt iLOTFtli THIC7OYi5i suing
M.
°Geothermal(Heating/Cooling Supply)
Resident
den &a
tial Water pply(single) - —
❑IadwtriallCwomcecial rt. I 11. 1 1.'
ial Water Supply(shared)
1i.cnotrr
°Irrigation O Wells>100,000 OPD FROM TO MA IMlI.1CIMINf MEIBOD k AMC
• °Monitoring apply Well: OR () R' Z'3 f 'e ""' V/
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eoY `� t'
• Injection Well: R R
❑Aquifer Recharge °Groundwater Remediation ft rt.
DAquifa Storage and Recovery ❑SalmityBtarier vSAND/GRAYL'LifACK cif■pptluble) •
FROM TO MATERIAL
°Aquifer Test DStormwater Drainage FROM {t, — rt. 1altflACRl Nf MzTRoD
ORxpe imeobl Technology ❑Subsidence Control" ft — R.
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Close
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°Geothermal( eosin Loop) °Tracer '20.DRILLING LOG fatback■ldltloaal sheets II amnesty)
g�mlingGRe4rm) DOsher(explain under I21 Remarks) FROM TO it. D (] (Lahr.ISTn N(Lahr.briaer wWr.�, k iip,Fa:.lay o
ft.4.Date Weil(")Completed: o '3-Z y Wen me ft. —•IL
g /6-1,4---t_ if
ft
5a.Well Location: ft -
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• Frsiity/pwasr Naar Fac ty IDS(if applicable) ft, ft.
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Pkysk Melrose.City,sad Zip mob' R — -
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J� r 2L REMARKS/r—
Patcet Ideutificatioa No.(PIN)
5b.Lelbede and leagltade In degreei/mi.atea/secends er decimal degrees: '
(if well5514,em lel/toes ie ratbcieet) —
to Z N �O r 2L Certifrution:
I 3K � .�J 7 �W
6.Is(are)The Well(s): P1Permaaeet er °Temporary 3 C — ���"z}
////llll ' ven,Coo4act r D
7.L skis a repair is■■existing well: OYu Sr Ne. Bysf 10asfora./hireby car*twrlhowell(r)weer(r�)c *�
7.rh/sIra arepalrearknew,welltin em Non ISA1VCACO2C:01A10,-114 CIC01C.0100IIeJ<Crnsnvicean'repair wider Ill remark:ssca�on or oa oho bock sf Air ssploln rho nerrr r of the (Phis record has kin provided b rho a s9 owner.
Somata*and rM(•
8.For GeoprebdDPT or Closed-Loop Geothermal Wells having the SYNC 23.Site diagramSra additions)well details:
construction,Geop eb 1 QW 1 is needed. Indicate TOTAL You mayuse the back of this page provide additional well construction in
• drilled: NUMBER of wells (add'See Over'is Restarts Box).You may also attach addi[iotla{
Pages dilates
7.'tealwell depth below land surface: •3 26 2,1� INSTRUCTIONS
For nrrdllple wed'I,sr alI dcprhr{l1�sr pr( -10200'swd: (ft)®l00) Submit this GW-I within 30 Jays e(well completion 10.Static water level below hp e[cash ` P per the Mewls':
rower t ►ice!4 l a q' T (J 24a. Fer All.welt!: Ori earin/F*se.-4 CO ,/� —r— — (ft) ��a p — {pan! form MSC, Division of Water Reaour- (DW f(/ rocaaiag Unit,1617 Raleigh,NC 27699-1617
11.Borehole dlawteter. 24b.For Li__ ecdorr yens;Copy to DWIs Underground{IR.)
12 Well eeasll7ctleR method: O r�•
Program,1636 MSC,Raleigh,NC 27699-1636•
Injection Control(IL
0.12.s.
is ae0ac.rwscx cable,dkact Ak seq) 1 t
24c.For Water S101 and O cQ I,ee couch' Geetiterioal ReturnWells:Copy to
mere titQla
• FOR TER SUPPLY W//FIlLLS ONLY: environmentalm
kal eat county
13a.Yield(6pm) v lid.Fer Water Wely_predid■ e►er 100 000 GPD:
Copy Malted of tut j (' Permit ratgsm, 6l f MS eig r, 27699-1611 to DWR,CCPC1
13kDidateeUorrtype; Ir
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