GW1-2021-01074_Well Construction - GW1_20210210

Jan, 29. 201810:58AM Env. Health , No. 6711 P.
WELL CONSTRUCTION RECORD(GW-11 For Internal Ux Only
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3.Well Use(check"ell use):
Water Supply Well• as a aurae wA L
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Geathermal(Heatinl/Cooling Supply) ideniial'Alain.supply(single) R. R ea
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Injection Well:
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Geothermal(Rcating/CoolingRectimi)
AquiSnTox QStormweler Drainage R h.Experimental Technology Subsidence Control A, B.
Geother al(Closed Loop) OTraetralter ex lmounderp2l Ramthi 111116111 TO o er turior.
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5b.LAlilude a Jmi longitude In degtaaaniabinsleusecoods or decimal dgms:
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B.L(ara)The WeII(s),10Permaoent or QTemporary Stsmnae ofCciritied Well Constructor Date
By sian�na rhir/urn I hereby care jy tour the WI(c)%os(une)cwunrtrtd,b o"orcNaro
7.$1615arepak to ao«toting well: C)Y« or o a,,h 15A AQlC 02C.0100 orIJANCAC 02CA200 Wdl Comolcuon StarWn*and Biala
l/shu lrarcph,F0o,a 8roa„wdt eaurranian t, wa aadasD/ant the Mom a/ore ropy o/rMs nroMMs berrpmnddroWe,NOowrwr.
nplr urber 92/rexarb.arw,or m,the back o/rMr fomr.
23.Site diagram or aJJieiaaal well details:
S.For GeoprobdDPT or Closed-Loop Geothermal WOttmyinz the same You may use the back of iha psgc to provide additional well site details or txell
concoction,only I GW-1 is needed. Indicate TOTAL"ft1f401021 commtction details. You nay slso tnsch additional psgc ifneaessvy.
cinlied: SIMM T1'AL INSTRUCT20Na
9.Total well depth below land surface: YQ 24e. For All Wells: Submit this form W Yuri 30 days of completion of Well
For mnnsple wens do aq'ITAS/dii fexm(emayle. ®r00•mdi !db) comnuction to the fmllowing'
10.Static water level heknT rip ofcasieg: (ft.) Divistoa of Water Resources,Iafarmallon Proetsstug Unit,
//wool Iml h abme em6rg roe-+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter pre.) 24b.For Injection Welts; In addition to smsdutg the fonnto the address in tea
Dv ) above,aim mbmir one copy of this form uathm 30 days of completion of Wll e
12.Well construction method: f\
(ie Voila.rotwy,able,direst pmq ern)� combustion t0 die tnllowmg
FOR WATER SUPPLY WELLS ONLY: Dtvisiom of Water Resources,Underground Injection Program,
1636 Mad So.Cemtce,Raleigh,NC 37699-16369-1tt6
Me.Yield(gpm) Metiod of lesh_Ned/ [U O 21e.For Water Supply @ lolventon WeRr: In addition to sending the form to
tit address(m) above, also submit one copy of this forth Wllldn 30 days of
13h,Disinfection type: Amounts: completion of Weil constriction to the county health department of the county
where conslricled.
Fy GW-1 North C.1in.D.p.rsmeu a(Fmmaaaial Quality-Dwkiaa IfWarcr Rcromcn Revised 2-22-2016'