GW1-2022-03483_Well Construction - GW1_20220223

WALL 9011tSTRUCTION RECORD(GW 1) For Internet use Only:
1.Wen Contractor information: f
o as\n�z- 14 14WA791RZONES
Wall CookactorName FROM DUCRDTMN
M K0 Q
xe Wet conn„�ee,c -• Imo_
To
fr. it. in. G
Company Name
14041M OR I MMMMdid2
2.Well Construedon Permit#-. mom To MAWMMM VMCKNM I MATEMAL
List all applicab uWl corlslructlon pgmdfs(i e-67C,Con%Sto4 Vwfmue,etc) ft. ft. in.
3.Well Use(checkwQ use)- & ft.
WaterSaPP?Y We»; 7.s
Z9.4=10UT
D VAA1'I3RAgricultural �Mtmicrpat/Public &Geothermal(Heating/Cooting Supply) dential Weber Supply(�rSle)IndushiaMommerdal [3ReddendelWaterSapp]y(shatvd)Wits •on TQ C6M&�!T OD&AMOUNTNon•WaterSapplp Well: ft.
onitoring � �
ecdon well:
� f6
AquifaRadmW DGrormdwabarRemediation ]A.sANDi vBL d
nomUcalIld
1090thermal
fferStmopatldRecovery 13SttifwBamier M TO MATERIAL MMMD
ifer Test DstemtwaterDreinage M ftetimental Tecnology Dsubsidcnce CMtml ft. &
thetmd(Closed Loop) Tracer 2QDRiLLi1M attaehaddttiouaIaf�sif alpatCoo' Retarn Other explain under#21 Rem�Cs) FROM TO DSSCRiPTtoN wtm aotlha� eau
ft. tl.
4.Date Wells)Corgpleteds z.l�o WellM# -
SA OULocation: D'
Facility/ownerName Facility M9(if applicable) ft. MAR 2 3 202?
Phys[calAddrew.(5ti.mmdtip ft. ft. vT ar
e��• r lli��(,
cod* rmcelydanfr&+atumxa(Pn� ` i
6b.Latitude and Iongitude in degreeslmimateslseconds or decimal degrees: M
(if�Belk
�4one'�!/`issui�cieat)N W 22. ' cation: I .
11
6.1s(am)the wells) ent or 13Teraporary Sisff=ofCQtiHadwell Contraetw Hate
7.1&this a re to an By Agafng this jft41 hereby anvy that the Wg4s)near(were)cwntraed In auatdmtee
pair exis ft well: YeS or DNo avUh 15ANCACO2C.0100 or15ANCAC 02C MW WeA Consrracfi=Stw dar&and dwa
tf thfs Isarepafr,fdroutknomcwau eanumcdan fnfwrnorianandexprafnthe nauQeofthe cW efthfsrecordh=b=provided to thewd1 vmw.
repah-under#21remarkosectfoaOren the barkofd*form, 23.Site diapmoraddidonalWelldefarlm
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells booing the some You may use the back of this page to provide additional welt site details or well
construction,onlq,i GW 1 is needed, indicate TOTALNtRvMM ofwells conMucfton dead You may also attach additional pages ifnecassM.
drilled:_ ,..)9. / 7SIMMI� DNfi
AL
For rind wall depthfis W below land soffiaces Ly�/ (ft.) yqa.For AII We4ss Submit this form within 30 of com tetion of well
Formatttpfe weirs rtat atrdepths ifdt$errnt(esnmpte-3Q200•art/d2QI00) co�yphpatothe following: P
10.Static water revel below bop of a MhV (ft) DIAdon of Water Resources,
.{/water levers above msirtg,use"+^ Irt40rm8dOD PsvCESSIDg unit
1617 Mall Service Center,Raleigh,NC 27699-1617
(ln.�
11.Borehole dfa ec: 24b.For Inteetion Wells: It M addition to sending the form to the address in 24a
12.WeIlconshnrNon metkod: above.also submit one copy of this form within 30 days of completion of well
04.aUM mtery,cable ditectp-k ete.) construction to Ste following:
FOR WAM SUPPLY WMIM ONLY. Dlv➢slon of WaterResom ,Uad wgeound Woodon Control progrna,,
16%Mai[Stavtoe Center,li @kb,NC IM N16M
13a.Yield(gpm) d l Method of test: 24c.lbr Water MMIX&In edian War In addition to sending the form to
13b.DL5infeNfon LjTse: "t the addreas(es) above; also submit one copy of this farm widda 3o days of
Amumb completion of well constraWan to the county heath department of the county
where cansuac�
FoanGW-1 Np �g �
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