GW1-2021-00485_Well Construction - GW1_20210210

Jan, 29. 2018 10:58AM Env. Health No. 6711 P. 1
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WELL CONSTRUCTION RECORD(GW-1) For heaermill Use Only:
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WdICNrbaeta Name ro 0
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NC djumnI&Cati6pm N liumber �//t�
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2f 1NN1eR'.CASINQORTUn1NG
2.WeII Coastructiw Permit a: ON ro orAlarrsa TRIti,2rf6a .LL s+A
Lhrol/opplimNe wolf rnuttvrdaa peon or it.e.Ew..Comoy.Smm,Fadoan,Mj - n• h• �
3.Well Use(cheehavell use): n' o• r
Water Supply Wen: ;"2291aJ1EERd�r` -
a+ 1"Adnil at" gNPEa NA A
_ AgficWtuml icipeFPublic D o, R
Geothemlal(Aeatinr/Cooling Supply) - Residential Waref Supply(single) b. IL it
_ InduatrieUComn+meiel ORtsweatul Water Supply(shartd) —
Inn lion -t NAT791AL r,OP&
Non-Water Supply Well: o• n
:)Monitoring Recovery h R.
Injection Well:
R R
Aquifef Recharge [lGroutdtwter Remedistion _
Aquifer Storage and Recovery 0S6linily Banner 1M051ND/CRTO MATENJU
PHGPACIt: -
AquiftrTcat OStormwater Drainage a n.
Bapenmental Technolagy ®Subsideme Control R h
Geothermal(Closed Loop) Tracer i'ffi "CMG iAC aifiiC]adingat'fkitr7ANau- 'i-_-_-..:__�-c,.—_
Geothef+rol(Remin Coolin Rerun 0111er ex lain under all Ramadra To sisw islet,het4wvhrelViwh
- R. R
d.Date Wells)Completed:L L� — Well 1Mt /C!i IL (/h / /C 4-•Sa.Well Lmaffom ALh G/'r,4%
L aulz( /3q/�Y/ Of. 2w- G h R
Paoi4ly/Ownf(ger PaoaiN ml(ifiglieepY R h
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Phrsttel AabaN.7W 2y h R
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Comb Pascal lA si6r6dJm No.(MN)
Sb.La fitude,and longitude In degrets/mtameslsecoads or decimal degree: �
(Irwin deldyr r TnMng n"u civet} aG^22.Certification: 4 O l' R
d Z,, �N / ,d W tom'u bzk WKI
6.h(are)The wtli(s)1%Permenent or Temporary 9i8aenoeo trti6ed Well Covaerror Due
BY rigoag lk,fast 1 hereby rertr/y dhar the WI({I was firers)Marrmrred or Moldiacs
7.h Ibis a repair loan tmistingwell: E)Yts or-dr. wob 13ANC4C 02C.0100 or OA NCAC 01C.Oh10 Wil Conmwcive Sw*n*and rhas
If,hir it a repoh,p0 wow bra,wall rwoiiuiah 1,4asroli anderplaithe muds,oft he ropy of*, owdlN,downprodMdas Or roll owner.
rep.,„Mel ell reanr6.eehan or an the back ofiMr form.
21 Site diagram at additional well details:
8.For GeoprobdDPT or Closed-Loops Geothermal Wells having the same You may use the back of this page to provide additional well site derails or well
construction,ontyl GW-1 is needed. Indicate TOTAL NUMBBR ofuens constntttiondeuiL+. You mayslw ettechaddititmalpages ifncccvery.
drilled: ? �j St U Tf�A1 INSTRUCTIONS
CTIONc
9.Total well depth below land surface: r7 c!5 YQ 2aa, For All Wells: Submit Otis form w7wm 30 days of completion of well
For malnp/e wells lutall depih./df¢rent(trample•3®206'and 20100)rU 9 .i�glnclion W the following:
10.Static water level below top of casing: - � l (11)[lJ1�Y Dhhion of Water Resources,Informallon Processlug Unit,
///veneer level o above awbtg,we"+" 1617 Men Scrvl a Center,Raleigh,NC 27699-1617
11,Borehole diameter (IL) // I:..,a � 24b.For Infection Willi: In addition to striding the form to the addra s in 29a
12.Well emstr eflon method: above,also submit one copy of this form within 30 days of cmmpletion of well
(i-c Mega,row y.cable.dims punk tlo.j— ' eonmuction to fl¢following.
Df---of Water Rdmirect,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY; 1636 Mad Service Conics,Raleigh,NC 27699-1636
t
13s.Yield(gpm) Methad of teth iJe,fJf 24t•For Water Sunoly,&Injection Wells; In addition to sending the form to
�IT the address(ea) ahwe, also submit one copy of this Rkm within 30 days of
131L Disinfection type: Y N Artnuat: completion of well cowniction to the couity health department of the romuy
writers conalnitted-
FonOW-I Nwth Center Depv+meatafEavnmseerl Qmliw-Miss=ofWattf Rmimot Revised2-22-2016'