GW1-2022-03428_Well Construction - GW1_20220318

Jan. 29. 2018 10:58AM Env. Health No. 6711 P. 1
WELL CONSTRUCTION RECORD(GW-1� For Intemol Use Only:
1.W Zontrglq hdormAtlo `
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WeIlContraetorName mom To DESCRIPTION
70ft No R• 6-Fin
NC Well CoatiacorCerdlicetionNumber l6.011IEttt'iYS[NIi'1 mttlii<ai tIIs: = I IF-"h5 Wei e. .ra:_wt,`'ER!z
FROM ro D1AM6fER TIFICXNESS IVIVER1AL
DoylrS ► o f( !� d 'Se r-ll6 r .01 ft. 1� ft. in. V'
CoatpaagN a
]ti IlVNERCASIai(}ORIE"IM(r? ihe+icit:ctesed lac`� :c�.:- yc --
2,Wel(Constructlon permit#. J FROM TO ASAMIM TIUCtaiEs4 MA'trtw+L
Llsru/loppliaadtevrRcanrrme6onpennit(1.e.Mccaunw-lant valiance.em) rt R•
3.Well Use(cheekwell use): n. tt to.
Water Supply%Veil: xl2^:3[?REBN¢ =- -- = =..__ . .. �,:: _�,-=•_= _
I DUAMM I SLOTSUM TntCMISS MATMUL
_lWouitural Mwicipallmlic 0 R, %
Geothermal(Rea iWCoofing Supply) Residential Water Supply(single)
_IndttstriaUCommcsCiol Resideatial Water Supply(shamd) :_ pl y >-_ �_Y•` ;, y ,,�„-�,•'-•.
Irrigation FRoal To M 7tRIAt DMACEMEM_ 'MMOD&ANo
lion-Water Supply Well: O 2 tr. t
Monitoring [}Recovery R. it.
7oJectlon Weil:
Aquifer Recharge QGroundwater Remediation
1R�i�7D1G1t/1efBGPtCC _.-• —'
AVif,-StoragcandRecovery 08alinityBossier 70 MA ..ACIUM M U
_AquiferTest �StortnwaterDrainage rt
Experimental Technology OSubside»ce Control rt• rt•
Geothermal(Closed Loop): OTreeer F10=D Bit'G aiWdiiddW0—wiy6mtr�L1-1. ';-_-
Gcothennel(Ilenting/C061,. Return Other(explain under#21 Remarks FROM To DFSCNtPfrWt alar,b■rdacss,wtYrosk sae ets.
R m
4.Date Well(s)Completed: Well ID# 63 h O n rd
n
5a.Well Location: 90 110 ft. r
Fawitylown"Name / Facility lDA(ifinlicalik) oV IL Qa R
physical Addis,.Chn and I .C. ILIL
County parcel men"estian No.(FIN)
5b.Latitude and longitude in degreeslminutea/second:or decimal degrees: /� c day �w
(ifweli field one lodlesw is sufi9ai■nt) 22:Certification: A V a g- y i +'I t
3 s-3GbGo g N Sl. l d�3.f5 W
6.Ia(ate)The weii(a)IOPexmeaent or OTemporary Stga■tmeo ertifiedWellConaactor Date
By fining t/di farat I hereby eere that the wfl(k oat(biers)eammtcred,h aaradaacs
7.B this A repair tome eltlsting teen: ❑Yes or t
wdh 1SAXCACO2C.0100orIJA NGICO2C.0200WeBCoannwlonSta tM*andtkata
((this isa repai►fina»1no wt weneoauruWan bfdrmarran fam the naftm gfthe �Pl of this reaoMlms Dees ptottded ro fha trait owmr.
repair under 821 r rh section oi,on the had of tktsfana
23.Site diagram otadditioAAiwell details:
&For GeoprobeMPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or Weil
construction,only 1 GW-1 is needed. Indicato TOTAL NUMBER of walls construction details.You may also attach additional pagos if necessary.
drilled: •Q SUBMITTAL IiNSTRtII"TfONS
9.Total well depth below land surface: ✓Q� (R•) 24a. For All Wells: Submit this form within 30 days oP completion of well
For mr!»plc welly futafl JV a fd fferrar(e=aetpie.3(�IOD•and 2g100) construction to the following:
r0.Static water level below top of eAsing: 30 __ (10 Division of Water Resources.Informntlon Processing Unit,
llwmaa low/isabaveemhewe+" 1617 Mail Service'Cetiter,Raleigh,MC 27699-1617
it Borehole diameter�(tn.) 24L For Inlecilon Wells: In addition to sending the formto the address in 24a
'bur 1 above,also submit one copy of this ibrm within 30 days of-completion of tvoil
it Well construction method: construction to die following:
(La siW.m1■ry,cable,&-I push do.)
Division of Water Resources,Underground Injeedon Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Ma$Service,Canter,Raleigh,NC 276991636
e
13s.Yield(gpin) Method of tesp 24e.For Water Sunnly&Inkaton Wells. In addition to sending the form to
the address(es)above, alsn subinit one copy of this form within 30 days of
13b.Dislnfecdon type: �!t Amount: 3`k ps completion of wall construction'to the county holth department of the county
where constructed.
FumGW-1 North CamlmaDepanmeat afEavimamund Quality-Divisian of Watu Rcsomcas Raised 2 22-2016