GW1-2022-05417_Well Construction - GW1_20220311

WELL CONSTRU ION RECg � (,-(; 11 Forint�inalUse
1.Well Contactor lnformatfon: - V
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3.Well Use(cheekwen user
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4.Date Wel!(s)Completed: 3-8 '2 z' wen mg !L n
S&Well Location:
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5b.Latitude and longitude in degrecs/minutwsecoads or dechn2l degrees:
(¢ Self I�lo�a ) 22.Cerffl on:
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6.Nan)the well(s): ermanent -or QTemperarp �Sa � S*=.ofCatifred; &U� I Daft
7.Is this a to ad '��°"8 *I ITierrby rhoirhenrd(s)vas(rr e)cm vm=daaaeecod=wv&h
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23.Site diagram or ad&90M21 well&clads:
S.For GeopiobtJDPT or Closed-Loop Geothermal Wells bavmg the same You may use file bads of this page to protide additional vdl comsh ucdon info
oaadruehoa,Culy 1 GW 1 is needed.7adicb-,TOTAL NUMBER ofwells (add`Sec Over'is Remaft Box).You may also attach additkeal pages ifmcesy,
drMed:
11 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below Ind surface:
Foraadtlpk�.e&Awandgev#,�on(�q&_3a)200'mrd2@ZM (� Submit thhGW-I within 30 days of wen completion per the fonowhW.
10.Static water level blow top of easing: G d 24a. For All Wells: Otigmal fora to Divwm of Water Rescuum (DWR).
Ifw tw kvd is asaw c=ft vc+' ( ( ) Infat&(aPsoeeSftUnit,1617M5C>Raleft NC27699-1617
IL Borehole diameter: I/ {m,) 24L Foi•Inue u Webs:Copy to DWR,Underguoumd 4-don Cuaw(TUC)
n ^ Progtam,1636 MSC,Raleigh,NC 27699-1636
i2.wen conatrcable, method: K data 24c.ForwaterSn ando Loo Geothermal(ia m�snta9.cable,diva pub,eoC) ,. A '
:. Ow eavaommeadal health epa must county ma�1a
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells vroaft over 100,M GPD:Copy tO.D
13a.Meld bm)_ Method of test: �-+� Petimt 1611 MSC,Ralei C 1 11 CCPCUA
13b.Di*fecdon type: Amount: d w
FannGW1' NatthCato]imaDepa:tmeotofFsvnomDeatalQmtity-DivivonofWsterRrsaaoes I Pxvixd6.6-2018