GW1-2021-00562_Well Construction - GW1_20210224

Jan. 29 2018 10:58AM Env. N:.aIth ND. 6711 P. 1
WFLL CONSTRUCTION RECORD(GW-1) ��^ For LtehmAl Um Only:
1.W 1 Contncte;Into Alto : - N
ftA�WATJM may.
well CwlwetofN®e 1. aym
NC(w�tacr�k.eCem6atton Number �d30U2LR' SINO'tdF'— f-
-YC I • ),� uY7,U Y '/ •�C(- �lC`P M tCn
RAM �—•-=
�A IdATIn3a1
2.Well Construction Permit 0:, 3 3 n eC rt. rt. 1&
I.he ell applifaNe veld rawrncuOnprWlu p.s U2C Cawy,AaN,FAHMMI,erc.J
3.Well Use(eheekwell me): _ -
:nseRBBeL:_
Water Supply Well, t o � um•�' -- MATERIAL
_Agncultml �MunicipoVPtrblic D 0. rt. ^'•
Geothermal 01coingfCoolinB Supply) deetial Were Supply(single) k IL ^
_LtdumrvUCon, ial _ Resideulul Water Supply(shared) ya•OROU ;:= —— :�"?=` ==
t1IX1 r To NA = D
N75-
As'Supply Walk
Q a
n ml;In ell: O. n.
Aquifr ReeNrge []Groudmter Remediation __1_ �:
Aquifer SrpW dRecovery Cimmity Bonier TU
Aquifer Tee �Stmmweter Drainage a rt.
Aeperimaw Technology ®Subsidence Control n 2
`%M dYtG eik3:iddlniMii.'-'•.-Rsecai- .-s:--•- '-';
Geotham4(C1med Loop) MT FIR 70 o wegwr+am.wwwa : ru.
_ Gnthcmwl(Neerin mlin Ronne Other ea late aide 921 Remarks 0 ft /m R Cc
n L
d.Dale Weil(s)Completed: +v411DM R
sea.Well Loeatiam ra
C%rg /7S3aS a n.
Pacdity/Owaes NamiePerr Fae0ib l0�1(if:pgicWb) /6
rt.
a a
Physical wddw,Cite 2+P
Cosetl Pwlldemi6emiea No.(?IN) .
Sb.Latitude and lohgltodc In degreWmisatWtecobds or decimal degrees:
(ifwell field.on bdUngit suddeek) 22 Certification: � �-
:35. ell3R 71(o N — 8/• S�S6c�� W Ila&
6.k(att)the wdl(s) Permaeel Or dTemponry
gigmrmeo mdwA Wen Caoeaetrd Dow
8y rvp:eg aks/erR/M.vby arsg red dw re7ttl sea Mere)mrmaerad in OttordOate
7.Dthisampn4msonbUagnu*. ❑Yn mt[No .nh ISA MCC 02C.0100wlieACK 02C.0200 WedC&wwmAaarwd2 cod Aura
(/rAirbargao,/Oaro hw+rwdrranrwaw kJarwaw.andaPaUr the moo.a(dD copy ofelon cudYr dmnpwh*dwraewtllovmr.
ppdr W"wa2lreawr6sertieoroedw WdA1rd0Jan 21 Site diagram or eddilkasl well tkaOs:
S.For GloprobelDPl or Closed-Loop Geothvmal Well,having Ore lime You may use the beck of this page toprovide AdditionalNell like details m well
construction,only 1 GW-I is needed. Inddcaa TOTAL NUMARR of Welk mnswniondeaib. You may also Attach additional page.if DMC9°'Y.
drilled: ` SDt16tITTA1INSrS.RUCIIONS
9.Total cell depth below lad sorLee: - J 00 2ea. For All Welk: Submit tltis farm vinhin 30 days of completion of woll
fbr nwlnpe veZG,rdfJepk%Jffivgv(avVfe.J®200'sad2®l0P) comwction metre following
10.Static Water level below top ofeesing: :;2 (ft) DlvbtouotWAte Resources,Information Procaslug Unit,
ffm er lower abMt ormee ma"+•' 1617 Mail Service Center,Raleigh,NC 27699-1617
EL Aare War diaamee .=--�"f—(la.) 24L For inlecll0e Wrier. in sddiliao to aadhtg the farm m the addrus in btu
1'L I r,t, `, shove,Also Wbmu one copy of W fo®w alin 30 days of completion of well
1itWWellconurnellon method: I �''a rrJ3,6 oorrs"Wun to the S2lbwmg,
(i.c aga,mury,able.data push eta)
Divitiae of Wader Anmlrnt,Underground Injection Control Program,
FOR WATER SUPPLY WALLS ONLY: 1636 Mad Servin Center,Raleigh,NC 27699-1636
130.Ykld(gpn) S�/'/�7 M4hed of rest. it, Fo Water bmq,Y fir l ubmon W W: 3n a this C m sealing the Corm fo
fix edrear(n) shove, aim aubmll orm copy of this fbrrl within 30 days of
13b.Disinfection type: H Amour. /C c completion of well conumuion to ffw county health depemrtmt of the county
where constructed.
FormGw-1 NmhCmlmnDgp w ofEeewemeael Qvelky-Division ofWatef nesowen Revived 2.22-2016'