GW1-2022-06345_Well Construction - GW1_20220705

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FELL CONS�'R1 IONT RECORD LQW 1) For Ia�nalUse
1.wen ODntM Drhformalion:
WA�tZONES
Tali CoahsctorName D1 Cn>irlYON
xa Wall y rB7
mom TO ID7AMB7$a mllaru,
Compm<yName t''
W „$/ * t$aaudciased�
2.Well Const'tvelioaPermit�: (r/ ( tetOaa— , ra
Listal(appltoabJewattcmrsTructionpermits(iaU;f�Conary.Srat�Ymtcmce:etG} p
3.WeII Use(ehe&,weu nw): tl. la.
Wat;erSnPPjY WeII: 17.5
GM m s� scar rvsnxanres
Agricultural dpoPublio Cl ft•. & Tn.
t3eothetmal(IieatiagJCooling Supply) �dential Water Supply,(single)
IndustriaWammemial DResidentlal Water Supply(sbamd)
Irri atioA FROM TQ HfA E"AL EMP MMM DdcAMQUNT
NaH-waierSnppjpWeli: p ft; /�Df�
Motlltoring covers► � �
Igjeciioa WeII: ! �'
Aq>uferRe*wp DGroundwWWRtmediefum ft. ft.
_ A9ttifbrstarageandRecw FROM 1 v>a[,rAc�re
� �SaliuityBaarier FROM To MAESniAL tt?aTaoD
Aquifer Test D5twnwaterDreinage fL ft.
B pedaleMdTccbnolov DSubsidencncaMol & ft.
Ueoth mal(ClosedLoop) E)Tracer 20.11RII,T�hIGLUG attachaddifiormisT�€sif
(ieothemal eatinglCao]ingRetaia Other(explainunder�2lRemadss) 1maM nBccaDercox rotor saithvek
ft. IL ,
4Date WeV(s)CoHtpleted:
• Sa.WeIILaeetion: �'• �• ,,-
facilltylOwnr- ame T— FacOityII (Ifappiirable) ft. fh MC ...q V.
AhysIddAddcesjG%utdMp ft; It.
County Puma idendficatiaaNb.M
fib.Latitude and longltude in degrees/n&uWseconds or decimal degrees:
Orwell 8ald.one ImangisM acient) 22. on:
Ao?D
6.18(am thewell(s) erlument erE3Teraporary s CartiSedWe11 Data
dy S18vtnS tltisfmm,l hereby certrjy thatthe»eA(s)revs(wets)amermreted is aazarTmrce
7.Ia ft a regairtoan eshiiagwe)1: Dyes OF 0 with25ANCAC01C.O]W orl3A.NCAC a2C MW WCU ConvructtnnSrm Bemis mddwa
TfrhistsazepalrfilloutfinomcwelTcvrfsrrucoTnnTvfrrrnmriortmtdefigtatrsrhe oftTre copy ofwsmcuzdhasbempravidedt*dmwao ner.
repak•utrd2r#21 remarlsseatlottarontbebar[ofthis}brm. :3.Sitetii8gl9moraddltflb�iwelldefaiL�
S.For OeopmbeMPT or Closed-Loop Geotherjuid Welkhaving tho same You may use tge ba&of this page to provide additional well site details or welt
construction,only IGwlisneede&ThdiamTOTALNUMSERofvvelis constmetiondataIlL.Ynnmay also attachadditionai pages ifneeessery.
drilled:
� �MPI°PAY�IlH.4TRIICTFUN
9.Tota!well
iveltsUstvlTdepthsifd�mt{ pie-3@20Q' Zmtd�IODg depth below land sm�ace:
Formuitlptew _- 24a.For Alt Welts: Submitfa¢this m within So days of completion of well
(�)
coastructioato the MGWing:
10.Shsticwatertevelbelowfopofa�siogr (ft.) Div OR ofWatesResflmcesWormation,PrncessingUldt,
1617 MaIISeivice Center,Itatefgh,NClfi699-16i7
ILL mIA dk besa (in.) 24b.ftintectlo Wells: In addition to s
nn �L ending tits form to the address is 249
12.Welteoastrucfion method:_ /(� above,also submit ane copy of this fora within 30 days of completion of well
(Le augmrutay.mblq�dicectpuslyetaJ CDa3lraCtlontotltefOIlowia
FOR WATE$SUPPLY WELW O1VLY: Ditilafon of Wa6erBesonr�,ifadergroundl>nleerlaa Canh+ol p1„
1636Ma &Tice(3MtW,Rat0,NCMan
I3a.Yield(gpm) _Method of test:bl"K iwi 24c.Far VyaOer Sanaly&Inlectlon Wets; Ta addifion to sending the form to
/ the tees) above also submit one copy of tym farm within 34 days of
13b.Dlsinfeet}an
fie: Arna=:_!k 0y^d� s w �CQUIPMOD,
o we construction to the county health depadment of tht:Gummy
FomrGW-1 NOAhCarolivaDepammentafEwAM mental
Qcality-llitddeaofWatm'12esautcea Revised2-U?016