GW1-2021-04015_Well Construction - GW1_20210823

828-622-7241 p•j
Felt 1519 05*,43p CleaiwaterWell Drilling -
W ELL CONSTRUCTION RECO (Gw—1 l lF nr ln(cmnn)Uge Only:
I-wid14.•,nntrastor Information: . ---- —
�.�.�.�Q,���S-- >---ores p Ion
%Veil Caouaelor Ntme (L ft. •
v�1C,�IXA11'fellCantmelatComficationNumber ��\Vnnn\1`r 1 111n1 g.ODiiSRCASINH' torrt►al � a
1lC 0 a� �
1 v L � l 1 ' ateoM RI TO �JL
Cwnpany Name +6.1fYNBR C ING t7R7'�►H1tVC �
yt To CIA TAI
2.Well Construction Permit#: f(, & I°
i.l+1 all ngrliroble wall rnnrtrtrm/on parlP+Os(La G.Cnt+ary,Stair V-yam:r,err_)
R. ft.
3.WON li9e(Cheek well use):
17.9CRB s r rxtctarttse resat.
Water Snpplp RteA: ro of
Agricultaral E)Mtmicipallpuhlic () o• tL
CKIMhcrsnal(Hesting1coolingSupply) Residential Water Suppiv(single)
Industrial/Commercial Residential Water Supply(shared) 18, Oijf MA L; eMPI.hCetMt;�itN Ddt MOI11Qr
raoM To
tM noon R. p IL 1
IVnn Iftler Supply WL41: tt• ft
Monitoring ©Recovery —
Injection ell: f1. it
Aquiferitecharge E3GroundwaterRcmcdiatine 19,3ANIllG(tAVBLPACK [I+ la
Salinity Barrier RDR
MA ywCEttt8l�rt1lCtII6D
aquifer storaae and Recnvery' Q• -
Aquifer Tc<t 133mrmwater Drainage
Subsidence Control M �-
kxperimenta)TrOutology (��(�
Geothermal [.1'(Closed Loop) T�r, �� LOG S fir• eit" "e
PROM
(ieothcrtnal Hcatin ing Return) 'Other arc lain under N21 Rcmnrks) it. t 1 ;nL
Wc111Uf1 ,� R• tt•
A.RAte W<tl(a)Cnrapleted: --� p
in.WellLaratinn:
r Facility[Di)(ifUrtplicable n'
,I�^h V n Nl t I J
�
5 (•,(1Kn 1J1,1 I V t�Li �
Pby cal Addracr,Clt ,and 7'
N�
C:,u,tty -- )nccnl fdantifientioa Na.
.'�.'�tit1' C_C•r.•
Fn"
51).Utfltude Ono i ni7ade indcgrw4lmimites/secoadsordecimnl degrm-c
(ii wall field,Una htt%4.is sntncicrit) c I I r 22.Certifies
SiEurol UfrketifiriVlenCantractnr Dtl<e
A.Is(arc)the welf(s) Pei iltaneot or ©ITemMrar?' rha{rhr.turf! ear fwarnJ cUnasvdrd in=Mrda»re
/t• prtipg dNs jbrm,I hrrrhvrmrnf} 61
i.is this a repair m an crdtttiag wdt }Xas or No it 1S.l tif_',tC'e2C_R100 er 1SA,YCAC OIC,010D Well Curtsfrncrinrr standardc am'rhm.r
;rd ls;x n r J_1r..fiM maJbrawn 1vdd1.V&,mcifaa ut(on ufrtan and exprairr the nn,un�.!jdra
Grey ofrlds record her Mar pmtgdad to the wall MWer.
rtynair tinder A 21 minarks sa:oan or m+11ir,hark 90OWS.faml. 2•g_ylte diagram or additional well demtls:
8.f or Geo rabeMPT or Closed-Lan Geatheruml Welis having fie same 1'9u may usU dHthe-S. Y u 1i1Y gaga to ch Mido adstpag fllell ces detai)s aI well
p P ayn9tntGinn drtails, You may also Mtach additional pages if necessary.
:xinalnlctinn,only 1 GW-I is needed. lildlc tto TOTAL NUM13ER of-m-Ils
drill+:d' —. _—_.. �<7 �nay..Tr.r.rn'Cl'Rt(CIYONfi
9.A'atnt well deptli bel(yw land surface:, (R) 2Ia. 6or A____�I.Wl�ls: Submit[ilia form aitlan 30 dabs of camp![uon of welt
I--nr mnlN,prc x r11.r fill afideprhr ifq�'er"It jrxampk-3C1N1�0��Mul;a11QOq oxistruction to the following:
10.Statie Water level below top of easing: _- 0t) Divlsiaa of Water Rewurees.lafhrotation processing Unit,
1!'aa(r?r hnz:!is r7rvlvu casing.Irann" •l )619 t�A Service Center,)Ralcigb,NC 27699-1617
ti.ilorehofedlsmetcr:�ed:��(lo•) 2tlb.Fes Iwlectiog t,Veilx In additian to sanding the form to the sddm a in 24a
atrave,also suhtni:one copy of this form w)Ihin 30 days of eomPletian of well
12-Wa construction mclbod: ( 'f�r—_ OKStruction to the following:
(i c,augc,mrtry.sable,divot t push.'Ac')
Division of W arcs Reaaut•cec.Underground 11{)ertion ControlProgram,
!bR WATERSSCPPLY WELLS ONLY: %36 mail Servi¢e eelnmr,RAt¢)gh,NC27699-1636
13R.Yield(gpm) ptethad of test:J . 24c Der Walcr SurlDly&fnitx on wilts in addition to s uldillg the lbrm to
the addtoss(cs) above,also submu one copy of this form within 30 days of
eomptetion of wven consunan to,the conitty health deoRnMent Of the comnY
t3h.1)islnfectian type: --— ,Amotmr. whore conanucted.
Raaatlrcea
Fain GW-1 Nc rth t mlinnAcpn1lmont of tin�trtinmt nrnl QtmGty-Atvisutn ox[Vase[
ReviseA2-22 Ial b