GW1-2022-06214_Well Construction - GW1_20220620

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WELL CONSTRUCTION RECORD(gn 1) For Internal Use Only:
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2.Well ConstructionPernuts. - G Most TO I urmmrmt I 't7t ooEss I st►TzML
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3.Well Use(eheckwall use):
1Voter Supply
pP Y FROM Tp DLu Mrga SLOTS= T MATERIAL
_Agricultural [}Municipal/Public 0 fr. fr. ��•
thermal(ReatingJC(olingsupply) MResidentialWaterSupply(sinp�) ft.
InduatrisUCammcreial DResideatial Water Supply(aharcd) -j8=4ttouT. _-_'=! ""•.`Y".'
_Irri ti0n �� ?r G lit TO MATEtirAL EMPIAMENI'MEIHODRAafOUNS
a: n
pion-tVaterSupplyWeil " n- C/ r� `r11r' A.t
Monitoring QRecovety R. ft.
Injection Well: W fr, fr.
_ AquiferReehargo OGmundwaterRemedietion
Aquifer Storage andRceovery dSalittif�iitfi�t ��y}r• ,,. >;Ros[ m MATERtAI. EMPtACCMENrbti`7KOn-•:.-
D U 600 m rt
AquiferTest _oStotmwater Drainage-
Experimental Technology Subsidence Control to 0'
Geotherstal(Closedloop).. }�Ttacer SHOD �3flG�it�lciaQdltlolwirlieetiCtn'u�io _-'--`�_`'-
➢AOht TO DFSCttIPIfON elver,turdheusolYmrk a ate.
_Geathutndl(Arating(CaoliingReturtt OtherLaluinundert3Zl Rome tks R CG
4.Date Well(s)Completed: welling li n' 7r? fr. li r ^�"�l f'+✓
5a JVell Location
CYfL fc.
Faa'liWOwnefName c t Facility tDk(if opyneabm) R It.
• ! ✓�� �oi'j/1,•(r f J!'Gt//rrr/ �����r� to n.
Physical Addrms,City.aad Zip
Coup, Perralldemifianiaallo(P1N)
sb.Latitude and lobgltnde In degrceslmiatttedaeeonds or deelmnl degrees:
(�Ilfleld.yaalladlongissu6tcieat) � � � � �� I 22.Certification: ,�,47.t��' i �
/J Ju o! p G w t I Z-- -
6.Ia(are)the well(a)IOPermenent or MTempor2ry Sfpinn ofetrUledWellconDnctor Dato
By iigning dui farm 1 herd6y eerttdy thor the trell(s)was(hare)mtuavered ai aacordaaoe
7.Is this a repair to an existing wets: Dyes or ONO with IV IVCAC 02C.0100 or ISANCAC 02C-0200 Well CoastntettonStarhiohb and that a
I(this isorepair,JNloitthmwtwdlmatnuuioninjarmaonmidmp lam the Tatum oft he coPyofthutwidAnbeenprortdsdtother nit turner
r,p rander02l rrmarla section oro,t the bockajthtsjmm. 23.Site diagram or additional well detalls:
8.For GeoprobelDPT a Closed-LoopCeothermal Wells having the some You may use the beck of this page to provide additional Drell site details or well
construction,only I GW-1 is needed. Lldicato TOTAL NUMBERofwrals conshuctiondetails.You may also attach additional pagra if necessary.
drilled: SnNflTTAL iNM(P1ON$
9.Total well deptb below had srrLuct G (h} 24a.For all Well Submit this farm widen 30 days of completion of well
For mntapkxeffs.t totl&PLY ffelml(u 0'and2@1d&) construction to the following:
10.Stade ivater level below top ofcasiago .3o (R•) Division of Water Resources,Information Proeesslug Unit
ffwarerletel itabotacasiag use"+" 1617 broil Scimce Cchiery Raleigh,NC 27699-1617
11.Borehole diameter. (In) 24b.For Inleellon Wells: In addition to sendotg the formto the address in 24n
above,also submit one copy of this fbim within 30 days of completion of wall
12.Well conslraetlon method: 3 � ( construction to the following:
(i.a auger.rotary.cable.ditecl pmb,eto.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY SMELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699106
13s.Yield(gran) t/ blethad of test: 0,if Ct" 24a.For Water Sunnly&Inleetton Wells: in addition to sending the form to
-tile addresses)above also submit one cupy of this form within 30 days of
13b.Disinfection type: 411= Amount: completion of wall cons=don to the county health department of the county
where constructed.
Form Gw-1 North C=liamDepartmzat afEavimamenml Quality-Division of Water Rwomecs Revised Z 22-2016"