GW1-2022-03479_Well Construction - GW1_20220323

WELL CONSMUMON RECORD(GWV-I) For Internal Use Only:
1.Weft Cbntractorinformatlon:
en L,v. r" 14.WATER ZQPM
Neu FROM ra 1 DISCM1 i
NO wen C*nhV erC—t;m - - '
in' .�� MATERIAL
Compan�yName
16.BMWCASINGORTUBING
2.Well Canstrcmdon Permits FRoaa To I MAMMM I ratcioeess MATs[ueL
Lig aliopplicableweil cmulmcfion p"dts(ia 67C,Comuy.State,l�miatrce,et�j R. ff: in.
3.Wdl Use(checkwell use):
WaterSnpply Well: 1.SC!RHM -
Agricuttural crpaUPDbilo ELM T° fi~ �, fa. sr
Geothermal(14eaknSiCcoUng Supply) tial Water Supply(single) ft im
dustrial/Commercial DReddentlel Water Supply(shared) M GROUT
Dn mom TO EMPLACEAUM OD&AMOUNT
IQon-WaberSWW Well: ` ft. P
Monitoring wvwy &
2dection WeII:
ft. ft.
AquiferRechmp ClGrowwaterRcmediation ly, elssviae, t3 rf
_ Rquifer Storage and Rtxovcry 0SalittityBmrier FROM TO MA'EY RUL ACSNII�PC D
Aquifer Test �StomrnaterDrainage ft- %
Expedmellyd TechnoloU Subsidence Control ft: %
Geothemtal(ClosedI.00p) Tracer O.DRILEMLOG(attwhadditiauatstmbff
Geothermd Caolin Retnm Other lain under#21 Remadts) MOM To Dsscs ox color aoohoets eta
R. ft. Lr�ir
4.Data Wells) lefed: w# / 1� (� ft• / it. G� t
. 5e.WeII Locations J�' $ R• �
ft. ft.
Feoihty/o(,wnn Name FacOi M9Gfapplicabla) ft. ft:
AllysladAdda9X1M=d.23p 275'7q f`. MAR 2
2I.R12&ARKS
CMAY Parcel Idmdfic2fi=Mo.(P" WOW
6b.Latitude and tongltade in degreestminoWseconds or decimal degrees:
Of well field,one latnus is sufficieat) 22. ti
36024132, 79016 Z! 1 '41D. el
(3.18(are)thewell(s) ermanent or OTemporary sivahloofcm dedwau canwAfm Dan
' tn8 SYY 819 fi*fom I harby an&that the wags)any(were)mnwucted in accoNm7ce
7.Is this a repair to an eAsftgweli: Dyes or Iwo %v1rh ISANCAC 02C.4100 orISANCAC 02C MOD Well ConsmecdonSwndmds and dwra
if rhls Isanwdr,fil out kwm well conmucdon infarnmdon and eaplato#x a==afthe Qopy oftilTncmd.has ban pmvldedtoft wellamur.
repairwlder#21 remarkrsudoaoron the backofttrisfarm. 23.Sitediagrantoraddfitional well details:
g.For 43wprabaWT or Qom-gyp Geodwrmal Welts bavmg the same You may use the back of this pogo to provide additional well site details or well
construction,only 1 GW-1 is needed. indicate TOTAL NUMBER ofvvells construd ion detaft.You may also attach additional pages ifneeessMy.
drilled: tIYIlZ°TAx,INQ7'RVCiTONS
9-Total well depth below land smdacer yqa•For An Wells: Submit this form within 30 d of completion of well
Formuldpk wells IW all depda ttFMkrw(awnple-3@200'oad2@1009
construction to the following
10.Statle water level below top of casing:if water level Is above casing.sus .r•" Division of Water Remurces,lnformation Processing Unit.,
p 1617 Mail Service Center,Raleigh,NC 27699-1617
U.Borehole diameter. tD Y� w{fa.) 24b.For bdectiog$gllst Iri addition to sending the form to the address in 24a
12.Weil conShMC ton method- *("rvl abo%also submit one copy of Ibis fxm within 30 days of completion of well
(Le auger:retan,eahk dhutpask eta.) cDns#nmtioato ft following
FOR WATER MY WELLS ONLY: Division of Waterlieso �
19� ,vndera andUdee>��1P.H..n,,
i6mMai!Service Centm,Re kh,NC2769NI636
13a.Yield(gpm) (9 Method of teW 610 t t)I.1 Fbr�iv k Iniec Wells: In addition to seadmg the farm to
13b.DisinfectlOn e• H'"f I _ Amok jg Du n r.CS the address shoves also sho also sulimit one Dopy of this form within 30 days of
RYA • T� completion of well eonsisueg,,n to the eefty health deparmlent of the couMy
Where cDnstraM&
Form GrW-1 NarthCarolmeDepa�mtoPBmtmnmmtetQrmticy-DivisioaoPWamrResanteas Revised2-22 2016