GW1-2022-05438_Well Construction - GW1_20220607

Jan. Zy. ZUld IMOM tnv. Heal In c•r��, aer r'ry lap. of l i r. 1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use nly-
1.MCC20111formallo :
SROM TO prSC MMIN
wen eoNraewmama R ig
ft. ft.
NCWtllGmm&CatifiationNumber .A
FRobt To DtAM R THtcintrss IUA
tt. v C.:
c0 7ti:'IIVNEtt@ASI10,01C'141 INGi....IhernieRvQ5v"0 . �-
XL wen Construction Pernhir#. o To orAatcrss craws sr:TSRrA1
Ust A l applicableWff emmnrcdaa peMdU(1e tf c.Camry•Stare•yfidenee•etc.) it
3.Well Use(cheekwell use): n. h
1— odwrinfil
rSppply� eti: =�icUito®1 Q hupal(Public 0 B. Rth"Mal(Maiting/Cooling supply) Resideatial water Supply(sit*) rt %uatsiaVCommereiol ❑Residential Water supply(shared)tion rROal IIMRIACCEIM-_i' EfHOD&ABIOUNPWater Supply Welk `i1)mdmrhagtionWell:ulferlteoharge rJ. GroundwaterRemediotionnifcrStwascandRecovary OSalinityBonier rRoor MATCRIAL cAcbtNrMrMOD
uiferTest 'DStomimter Drainage k
perimentalTechnology 13SubsidenceControlothermal(Closed Loop) OTraeer {1d (:3:0'ng/CooNg Return Other Main ander#21 Remarks 6LTo
OfSCHIPrro stet,6atdnear,wtyrork Inf e1e.
IL g� C G
4.Date Well(s)Completed.s a Well MM 162 it 3 5^ n.
5a.Well Localtom R2.2 c
Faa7ity/IJtvactNaau Facility Mi rfippticabb) rt• rt
it.
phrieal Aa&M&city,cad Tip
Carry Pucelidemifieatioallo(Pilo)
Sh.Latitude and longitude in dcgreea/mloutes/seconds or decimal degrees:
(irvall gala,m:a IatAong is suftim) 2z CerdLeation: Ma WTM
6.B(Are)the wen(s)a$Permanent or OTamporary a(gaature ottutified Wen CouVactor Date
By sigrdng tlit facer.1 hereby cer*lhar the WA(t)xdr(were)munueted:n amtdwee
7.Is this a repair to an existing weft: E)Yes or D10 ,vial 19ANCAC 02C.0100 of iJA kk 02C.0200 Well CO,tnnanon S0140wt and that a
((chit is rep*,Jip aid hwwrwelltdnamaiahlnformetion andarplaa the►mbn of the cW of this emidhaa beanpmvfdtdro the ivrpowner.
repair wa&r 021 numb sewon a?on the bad ofWrfa►aa 23.Site diagram or additional well details:
L For GeoprobelDPT or Ciosed•Loop Geothermal Wells having the same You may use the back of this page to provide additional xsli site details or well
conauction,only 1 OW-1 is needed.Indicate TOTAL NUMSAR of-16 construction details. You may also attach additional paps if necessary.
drilled RIiRMiTTAL iNSPR(C7•IONS
9.Total well depth below land surface: G (n•3 24a.Par All Wells: Submit this tame within 30 days of completion of well
For mulapreVeto jut d/4Ihe ifdif ferent(aampre.3@200'M d 2®10&) cmmuuetion to the following:
10.Static water Ievel below top of casing: 7 e) (ft) Division of Water Resources,Information Processlug Unik
4rvaror IMI It Above auia&tas+" i617,,Mail Service Cwtrt lialelg,14 NC 27699-1617
11,13orehole diameter. V1j (tic.) 24b,For Infeetion Wetic In addition to send ni;the faun to the address in 24a
\ r above,also submit one copy of 6S from within 30 days of completion of well
12.Well construction method: constrtsctionto die fillowing:
(ia auger,raa*.table.aired pmlt tio.) -
Dwiston of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centel•,Raleigh,NC 276991636
13a.Yield(gPin) Method of test: 24e.For Water Supply&Infection Wells: in addition to sending the form to
/� the address(es)above, also submit one copy of this tam within 30 days of
131 Disinfection type: 1 r Amount. completion of wall construction to the county tKalth depanment of the county
where conducted.
Fo MOW-1 NorthCmotmnnepar mew atEdvimmneatei Quality-Divisian orWater ttwonhtea navised2 22-2016'