GW1-2021-02719_Well Construction - GW1_20210930

VVM CONSTRUCTION RECORD(GW-1) For IntemdUse;Only.
L Wen Cont metor Information:
T, St2,n Q.hs 011 14.wATSRzoNES
1tR01Vi ro n�scR>PTaon
Weil ContteeterName s $ J p , n S
ali a�. %
NC%dell ConuaetorCertification Nmabw 11%OUM CASH ft mold-wed welts OR id10r[i
Stephensa is Weli Drilling, Inc. FRM TO DIABERM TWOMMS MAXIMEAi.
CompeayName
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2.Well Construction Pervnitg: �3-1 16.IIViVSR To TMOCOOM naarteRMr
List O/l w9coble Wulf O mtrutsrmtparzftr(Le.L►1C Conatl.S�Yana=em) fL
3.Well Use(check well use): $'
Water Supply VM; mom TO M4MEr6R SLOTiil$ tHATcsrAL
culgnal tcnpa}/Pnblic >Z n. in.
Geothermal(HMb4Cooling SupplY) �dattisi WaterSuPldY(sic) IL IL
Industrial/Commer�cciai OltesidentialWaterSupplY( IR.GROUr
n ro brA7n:siAL E&1PLA 1vmt8on 8
Mou,Water Supply Well: $ & /� SO I
Monitoring IL C r
Injecdon Welt: M
ttiferRecharge arotmdtuaterRemednatton MSAND/GRAVSL
Aquifer Storage and Recovery [:Salinity Barden FRob1 TO MATMAL ERRActtim btleTlton
uiferTest A & IL
etimental Technolou [l5nbsideatce Connnl fL
Geothermal(Closed Loop) [)Tracer m DRIIdilYC I.OG attach additiaaaislarxm
oOw
Geothermal(Heatin CootingRemm Other( lainunderMlRemulm)
�t ft, R, f JQ
4.Date Wells)Completed: `-a\'ak. WeB m n' a R' I C �!
Sa.VVeri Location:
MALi all
QT re,skosen P dEL, L>_c 40\ & QAir Lick
Facility/OemerName FacMWM.'(ifWIJcoblc) IL
sg A. AID,
Physical Addtlxs.CWY.ao ZiP R �
�rra��r;lle Ig3o�o��c� la3 21.E
l�azcelIdenaifioadoallo(PIId) nit
Coimry .,
Infiorr~.3 i I ci-ion
Sb.Latitude and longitude in degrees/minutes/secOm s or dedolld degrees:
(irwell field.one leUtang is suffident) 22.Ceihnmaon:
3S° !(-V' N W k�� T. �-al- a�
6.55(siar)t w�(sl t or [Temponry swa=Urcertmed Wen cionowwo Dale
VV By zfvft d*jb=,rhereby coo rfmr OreWOV)nor 6MV)aongrUcaf is a aa-dwee
?.IS thlsa repair to as edisti'n9,wa-- Oyes or Q J6 twh rSAMW MC.0100 arZ.0 NCAC CZC.M WegCo u&ucntmt Sondw*m,d that a
ifOits is arepafr;fdl outbwwn well connmdimt btjmmatian mdopla n dtomtme ofdw capyofft r rord hashee»pravfded to thettaamer.
rape�runder0�reamrlssedfonoronOcebarlrgjthfsfarm 23.9tedlegramoraddiliondwelidetaft
L For GeoprobeMPT or Closed-Loop Geothermal Wells baviag the same You may use the back of this pep to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL M)MBER of web construction details.Yonlnay also attach additional pages ifnecessary.
dn'lled ® � SUBMITTAL INSMUtrTlONS
9.Total well depth bdow Iand surface: OQ 24a.Ay An Wens: Submit this farm within 30 days of completion of well
Forn ufGpfe wags ftstafl dep&jrdVerart le OW&-3WG9'dnd?(a 6M coaMaction to the fohloMV
10.Static water level below top of casing: �Q ( ) Division of Water ResotmeS,Information Processing Unit,
Ijtmrerlevef fs atone use`r` 1617 Mail Service Qntff,Raleigh,NC 27699-1617
1L Borehole diameter: Q A ( ) 24b.For Iniectlon Wells: ra addition to sending the foam to the address in 24a
12.Wen coastrnetioa method: /:t t' tNq y I O�r%I above,also submit one copy of this form within 30 days of completion of well
construction t o the following:
(i.a auger,whom cobl%diteetpusit,eta)
Division of Water Resource 'Underground Iq(edion Control Program,
FOR WATER SUPPLY WELLS ONLY 1636 Mall Service Center,ReleiglyNC 27699-16M
13a.Yield(gpm) d Metbod of test: 24c For Water S>mniv tit 7aiestima Wens: In addition to sending the farm to
the addMs(es)ahatr+e, also submit one cW of this foam within 30 days of
13b.Disinfection type: T Amount �- �b. completion of well construction to the:county health department of the county
when constructed
F,,.,,,rw t NwMC mrumD=ubnenaarFavnonmenWomnty-DivMonofVhdwResmcas Revised2-222016