GW1-2021-02044_Well Construction - GW1_20210620

Jan. 29. 2018 10:58AM Env. Health No. 6711 P.
WELL CONSTRUCTION RECORD(GW-1� or Internal Use Only: —
1.well Coovactor Info tlan
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2.Wd1 Constrngkn Ptswit ii: ( moat To mti+tY vas
Litfall opplicoor acoarvirefianpanatu 11lC Corny,Swm Yoriasee•ea:) R. +ft =
la.
3.Well Use(checkwell use): n.ater Supply 1VtU
TO^ n .-$_ sLerrIIffi TItIC MATEML
Agricult u d kWyPublic O R, I a I ill.
Gcothatnal(Henting(Cooling Supply) r3i.,idential Water Supply(single) IL (L 6s
_hultattial/Cammeteial_ Oftesdeutial Water SWly(shered) -
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tint MA AL titptl�tFNf)SEt110D3 u[li
Non-Waiter Supply Well oR R �. .�N i rZ d( lyy
Monuomg E)Reeavesy in. It.
Injection Well: —
- Aquifer RectwBo QGmundxmterMnedietion It• R _
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Aquzfer Storage and Rcaavcry 0saimily Bouier laser To HATEImtt � —-
_ AgvikrTcsc ostormvaaltrDminage n R. —
E?-imental Technology QSttbsidrAce control tti iL
Geothtstnal(Glared Lapp) Tracer -
S4(!3f ifoh,h-d emi sWhsh.
Geothumel(Arating/Cooli R.e�n)aa Oti►er - uddaFZl Remarks To nE
d.Date Weil(:)Cotaptetc °r �� /en rL
5a.Well Location:
Raci6V0MtfNVa= aatitrMJ614 1-b]-) u M
Pbyzkal A&h-,%My,-64p n n. MN 2
C—W 'a-(PIN) Information Processing Unil
ulyR becrion
5b.Latitude l+nd lobgltnde in degteeslminutealseconds or dedmal degrees:� 22 'C boa:
J
N 1 / oy t
6.Lt(srt)Ihetrell(s)eFet'otaneat or DTemporary 9iinanaeof WeIIC®oaaar Daro
By sipnV ehfttorsi I hereby eeald-thar the vd4o iron(i m)mmnoerrd a ancordoaa
7.&this a repair to an e7t(sting wW: [OV. or a *h M"02C.01M or IM MGC OX.'A M Brill ConnniaMR Sojelor*oaddan a
(/rlds is orepayfM wd hw—xdlwss—exm,hjknWd .andarpiam the MVM of the adpy4f his.Bead Ear hetapraif*d'in tee m*oar
repair:mder all ru aka se row or on the back ojthtr form.
23-Site diagram or additional wdl details:
&For Geoprobe/DPT or Cloaed•Loop Geothermal Walla having the came You niay use ttu beck of this page to pmvide additional%MH site details or.veil
cotcviuction,a*I GW-1 is needed- Indicam TOTAL NUMMM of usl(s construction details. You msr also attach additional pages if neeetsary.
drilled SU M ML INsI RUC1 IP-11
9.Total well doptb belowhud sorfaee: (R•) 24L For all Wells Submit ibis forts Wi0lin 30 der of
FarmidaptoWeft Grrarldeprlisld�%Zw �l+ie-2t �'@ �t days completion of W011
conswctien to fire Following:
10.Static waler level btlmr top of casing: (R) DtvWa of Water Resources.Information Fmceulag Unit;
ifwmar rest u abora suing,era-+-z 1617,NUil Service Center,Rateigh,I4C 27699-1617
IL Bareifale diameter. 01L) 24b.For inledloa Wens fit addition to srndhtg dw fiinn to the addrm in 24n
a WeB construction method; submit
above,also one copy of this form vAtbin 30 days of completion of well
(L-anger•mu*.cable.di-p»sit,eta) catstruction iv the folbvemg.
FOR WATER SUPPLY tAUM CMY: Divisor of Water Resources,Underground Injetilon Control Program,
1636 Maid Service Cantu,Raleigh,NC 27699-M
IX Yield(9pm) /14, Sfethod oftesC l L t A.For Water Supply&Nec on'lrl ells In addition to sending tba from to
the addmis cs) abovq also srbmit ate copy of this form Within 30 dogs of
131L Didnkcdoa type: Amount: completion of well cortsttuckil to tlat cowry tsealth department of the county
whew eonaTucted.