GW1-2022-01554_Well Construction - GW1_20220120

WELL eONBTRUCTION xEoa For Internal Use only: �-
1. elIContmetorInformation:
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Wen CootractorNae ^ FBOMTziTO DESCRTPITON
NC Wen CC=6nW cadfiok,
--MO fERCASi11TG fm?mfi)iFeisedWab OBMaR' .o.%..
; i;ice :.✓" FROM TO DIAMETER I Tammaoss v�•nsr.r.
ComPmp Name _ !,(� R R m.
O/�O iiG II�iSRCJ1.SR�IGORTUBING Emil •, ei. r�
2-Well Constriction remit s:_ V wont ro Dzer�ax ®s srsmvsi,:
IJstaII oppflmble wed maarctbnP l�L11C Cormry,Smrt Ymimrx,ae) -(� R a R S 7 in
3.WeR Use(eheckwenuse):
Water Sggdy Wa. C -, a.'v�;=ww,
OAgicaltmel ANOM TO DTAMMIM . MOrSIM~ T MATERrAL
OMunieipal/Pccblic R
CGwffi=al(Reapag/Coohng Shy) J016adeatw Water Supply(single) R ft.
07ndushiaVCammaeial OResidential Water Supply(spaced) _
-Chrigstion Owens> 7&-GROUTt..
100 WO GPD FROM TO JMAMMUL WWPLA.=RMSMODlAMOUNr
Noe-Watw SnppF—Welh R R
OM g OR=very
- Injection Well: R R .
OAgafferRechege E313m mdwalerxemediation $ R .
iI9 SfiNID!(3tTAOV BLM" RAOAgmr Stmp and Recovery OSlfi&yBarzia ` �v`•' E f �+.
II1n4ACQ�@rrIAL1319D
OAqu ferTest OStomzvraterDtainage $ R
0RgmimenWTechno1ogy ❑Subsidence Control R R
dal(Clued 14%) OTzacer -20:DRILIa1G IAG aeli idditinmil�eeti'if'
CGeothemLal(See M9 CoolmgReRtm) OOthex(cg9am under#21 Remade) ADM TO DFSCszeaoN mte ya.cv„ac�r Sao
R R
4.Date Wells)Completed: ! —!3-ZZ Well DM R R e
Ss.Well Location: R R r
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F Nnme FaaZay IDk(ifvPr-le) $ i R
ft. R a
PlysiW AA&m Ci%aodTp R R
(N i I'.N rZY�REMAR85: ` •,�:.'=kir--,��• .
�Y Peeeel Id oallo.(MO
Sb.Latitude and longitude in degrees/mmutestseconds or decimal degrees:
(ifwrIl&14eneho ngissoffieieat)- ' 22.Certification:
6.Is(are)the well(s): �rmanent ''or OTe / >8 of d. Die Z
9 c
BY•+r8mbi8drfbM the rbycvr*rhrirdwweg(s)win(wem)cvnsvu=da:aawnia roewah
7.Isthisarepairtoane3dstiagwe&— 03tes or 0 ISANGtCO2C.0100or15AICACO2C.0200WrdCpavuMwrS1mdmehmdd�aaaopy
Ifdw is a rrp�ftll a+ebrown well amrarKdaa by6rmmron arad espfa6r dx im+ra:ofrhe efdds ri+mrdhar bearpnrvrdrd m the rreII ornv.,.�
rear�o+d�!?Ironoslssaertorroronrheba ofddsform 2g.-Sift.diagram oraditonal well details:
S.For GeoprobeMPT or Closed-Loop Geothermal Wells having the same Yon may use the back of this page to pra4ide additional well cosishucticn info
consiructim only 1 GW 1 is•Dee3ed.Indicate TOTAL NUMBER ofwelis. (add'See Over'in R=tdcs Box).You may also abch addifimaal pages ifnecessaty.
drill
24.SUBMITTAL INSTRUCTIONS
9.Fornadd�dlrWW�w lsnd surface:— - a O (f� Submit this GW-1 within 30 days of well completion the folio Ph dgheljajvva(a+ompfe-3@200'm+d2@100) Ys mP P� �.
10.Static water level below top of easing: O A) 24a. For All Wells: Original form to Division. of Water Resoucas (DWR),
1/,s,ar�te+,rlrsaZoeeomd �u«+- t/ W=n9o11ProcessingUnit 1617NISC,Raleigb.NC276WI617
1L Borehole diameter. G 'r!d (tn) 24b.For Inieetion Wens:Copy toy DWR,LTndergrnmd Injection Coatzd(IUC)
Pmptam,1636 MSC,Raleigh,NC 27699-1636 •.
1
12.Wen eonsfrnctioa method:__I bT31+,— ArY 24c.For Water Snpp�d Open-Loop Geothermal Return Wells:Copy to the
(ie++ rotay,•eehk,dnactpo�L,etc) COnniy envuonmrtdal epat[tment couatY iu�ea
FOR WATER SUPPLY WFJ.JS ONLY: M For Water Wens profteing over 100M GM.COPY to.DWIR CCPC(JA
F=itProgtam,1611 MSC,Ralei C 9 Sil l+
13a.Ytdd(Yprn) 3 Method of test: �J►,.�
13b.Ditimfeetion type: Amonair It, n—
Fomt GW 1' Noah Cacoffia Depstunew ofEnvno=cml Quality-Division of WattrRes ==' Rrr;ud 6--2018