GW1-2021-00484_Well Construction - GW1_20210210

Jan. 29. 2018 10:58AM Env. Health No. 6711 F. 1
WELL CONSTRUCTION RECORD(GW-1) orintemel Um Only:
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2.Well Construetioo permit a: / (p 7J, mom MAMMA
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3.Well Use(check well use): rt' R IL
Wiser Supply Were1 10 1 1sow MAIFIERIAL
_Agriouttural ipaVPublic 0 n. R �•
Geothemal(Heatint/Cooling Supply) _ Residential Water Supply(single) R. R iti
_InduatriaUCommrreiel [31ttaideatial Water Supply(shared) /n..0
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Non-Wafer Supply Well! r-
Monitoring 011ecovery R R.
Injection Well: R R
Aquifer Recharge ❑Groundwater Remediation
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Aquifer Storage and Recovery 08thnity,Barrier aft To at,& rn 1aMPUC¢NENI'M
_ AquiferTtat ❑StarmwsterDrainage m h.
Experimental Technology ®Subsidence Control to R
Geothermal(Cloned Loop) OTrncer 00.D 'ummaLoC'aita 1kiilntiiiii a7fti«tna - -
_ Geothersel(Ncatin Cooling Rennes UMr ex Into under N21 RemnMs 12OH r0 OCdCn roN al. a rereyraWrark
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J.Date Wells)Complele�Wen IDa Cp R R ' bn
5a.Wlell Location,
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i6p(Oaurllaete Facility LDY(ff:pali-W-) R R
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Physral AJLal,Ciy,wd4 R R
County PalMeml6emloa Na(PM)
St.W(Rude and longitude In degreeslminuteslsecondf or decimal degrees: // G
(ifwNl gallon Iesumcimt) — 2L Certirleatioo:
6.b(are)Ihewe11(s)10P"—nest or 171Temparary sigoanaear it Dab
By rip1mg chit fore,f hereby centfy Ihar the well(k)un,/wCreJ rolum lod o,rcondasis
7.Is This a"Fair to so ex(stingwell: Elves or 0Nn with 15A NGC 02C.0100 or I5A dCAC 02C.0200 114r11 Corumecaus STwx+oede ad rhala
f/ekh 0o ri ft of ion 6ror,wdt eantuncum1.) sari a ad mpianl he Mom olehe °OAya/rhls MWdhat brexprowecd N the tvdl oxvnn
,par wd,121,mnrkt cecden or an he back a/rMs/arm. 23.Site dugram or additional well details:
S.For GeoprobeMPT or Closed-Loop Geothermal Wells having the same You may use The beck of this page to provide additional well site details an well
construction,only)GW-1 is needed. Indicate TOTAL NUMBBR of wells construction details. You may also much adddi oral pages if necessary,
drilled: STDIntITTAL INSTRUaTONS
9.Total well depth below laud surface: (R.] g(A, r AT Wells: Submit this foam within 30 days of completion of well
For m4aph writs loraldepeh.i/dpe,nr(eaoayle•3®200' 2®10b)(r'] �) c16"mtmeteontothefolloveing:
10.Slade water laud below top o[asing: ` CU (R.) Division of Water Raourtts,Informaton Processing Unit,
//rrmer Intl v obsa emurg,me"+" 1617,Msil Se"im Center,Raleigh,NC 27699-1617
11.Borehole diamctm to (In.) 266.For intestines Wells. In addition to scridurg the forma the address in tea
�1 L_/_ r above,also submit one copy of this form within 30 days of completion of well
Well eo 12.Well method: /\ Tc-r construction to elm following:
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Division of Water Resoarees,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONIrYI 1636 Mad Services Center,Raleigh,NC 27699-1636
139.Yield(gpm) � 6felhod of lqC r 24e.For Water Supply&Injecton Wens: In additon to sending the form to
the address(ce) above, ohm submit one copy of this form within 30 days of
136.Disinfection,U'►C Amount: the
of well construction to the cowtre health dclunweot of the county
ahem consrructed.
FwmGw-1 No hC.1im Depmmtew ofEatirmraeaul Quality-DMian ofWaees Retomees R.evieed2-22-2016