GW1-2022-06166_Well Construction - GW1_20220701

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WELL CONS' LMON RECORD fGW 1) For InternalUse Only:
1.wefI Confrra(cclarTnformatiioon�:
JQ 1^ lJ L ZONES - 7
Well Conft t nme FROM TO DISSCRiP�lTON
Slo 14 ZOO 1 -jE' f
HC Well G`ontrmeorGse$mo®27� '
Ur
l ME FROM TO Dlt�METEA 7MCSN838 MATERIAL.
CompanyNama � � � t'o �• � ,�,2-�
161NNBHCASINGORTIIBING lHemmtdosed-lan
2-well COnstructionPermit — — �I)Z FROM To DMIETER THIGKtt�9S MATsasa�
List all applicable wait constrnetlon permits(ia.67C,Comuy,State,Yadance,era)
3.Well Use(checkwell no): ft. ft tn.
Watersupplyweli: 17.SCREEN
RROM ITO I D RTAWQ17$• FTwrfVwv&a IMATPRtAt
Agricultural tcrpaUPubilo O, ft. Ia.
8Geothermal(Heating/Cooling Supply) oPtesidential Water Supply(single)
1ndustdal/Commercid DResidentlai Water supply(sbared) 1S;GROUT
lmgoon FROM TO MATERIAL EMYLAt T.1�OD&AMUUNT
Non Watersupplywall: tI: fr. 3 , t,
. Monitaring cwery tt ct r
1weeHon wen: ,
fr. ct,
AquMrRe*wp DCaoundwamrRemediation SANDIGdtAViti,PACg it' Umb1
_ AgttiferStmVendRecwery DSalh tyBan1w FROM TO IM.7acrer- MgrgOD
Aquifer Test 0StomtwaterDrainage ft. ft
ftedmental TechuoloV DSubsidmce Cor>frol ft ft
Qeothetmal(Closed Inop) fDTracer 20.DRII,LINGIAG aHaehadditionaIsh�fsi€
acothermel waLwJCoolmgRetum Other Iainunder#21Lcnm ts) 'ROM ITO DsseslPTcoN color cactiadc etc
4.Date Weil(s)Completed: U Well ID#
go.Wen Location: R•
�iV� t�r- I Ct ft
Fecilityl0►vnarl5ame FacilityM#(ifapplitable) �• ft d o�.w r,. a
A ft. ft.
r �/�'1 ter. /a,., J��i��-• I�l'
MysicalAddress.Cl%mdzp 2'w 1.3 ft. ft.
V� 0 7.q9 255/)�S99 2I.RS>,SdRSS ��.��
Co Parcal2deati$ Nn.(PII� a-c cam: 'Q E,1 3
fib.LatIluude and Iongltude in degrees/minuteslseconds or decimal degrees: 12=
(iEwell field,one laUlong is sufiioient) 22.Ce ti .
36.13�;.y - 79: b 9 962-7 w
el—A 40 - A T02,41-0 r—13-z7
b.Ts(are)the well(s)�ermanent or 13Tempo=7 o£CettiHedWeu r Data
3y'719wn8:ft farm,I harek,GwVY tharthe lwu(s)was(UM)cmuaacled in accordance
7-Ts this a repair to an es lingwel. E37es or Me with 1SANCACO2C.0100 orISANCAC 02C dr20013'ell ConslracNanSkwdards and theta
If rhts tsaaepair,fi l outAnom well canmvcdon info =toaand eaplarautenoaeafthe COPYofilT record has beenpr VI&I to me well rnvner.
repalrzwder#21 remarksectlonaron the ba&vjdMrjarm.
33.Site diagtmmoraddibimW well debdLv.
8.For GeopmbeMPT or Cdosed•Leop Geothex-md Wells baying the same You may use the back of this page to provide additional well site detar'ts or well
construction,only 1 GW 1 is needed.Thdiom TOTALNUhMER of-wells; conshudion det0i.Yon may also attach additional pages ifnetmssmy.
drilled:
S1'IBMI'i_'i_'AT_.INCT_R_IICTFONS
9,Toda1 well depth below land sol'Pace:_- S�7 7 (ft) 24E6 For All Wells: Submit this form within 30 days of completion of well
Formutirple tuelis fist alldepths lfdrffermt(example-3@200'cmd1Q1009 constructiontothefbHowing:
10.Staticwaterlevelbelowtapefeasing: �Z {ft.) DlvWonofWaterBewurcesInformation Processing Unik
4FUM-er level Is above aastng,use'a-" 1617 AMService Center,Raleigh,NC 17699-1617
lI.Borehole diameter: (0-6 _(�,) 24b.For Inlecdon Wells: In addition to sending the farm to the address in 24a
12.Well conslraction method:- �z.�.il above,also submit one copy of this form within 30 days of completion of well
C�e-�! .cable directpasia,eta) construetionto the following:
FOR WAM SUPPLY WRO OMY: . DlvUlon ofWaterResouraw Underground bdectlon c3ontmi p,�,g.M'�
1636 Mail Service Center,YW@kh,NC 27699-106
13a.Yield(pin) Method of tesk�Io c.JA 24c.kbr Water Snmrly Sr ni w-w w�; Tit addition to seeding lire form to.
,pp the addrass(es) above; also'submit one copy of tills form within 30 days of
13b.Disinfection type: 4MMM (D AN ni.r s completion of well construction in the couaty Health deparhucnt of the wall{,
where constructed_
FomxGW-1 NortBCatniiaaDepa�entofBnvimnmenmi
Quality-Diviaioaof Watmlt�vntces Revised212 20i6