GW1-2022-06404_Well Construction - GW1_20220603

"t iilll�V
WELL CONSTRUCHONRECORD CAW_ Forrzltemat�7seo�tty:
I.Wen Co =�ractoriiiformaHoa:
WAMMZONIM
Nell CatlhtactorName OM oN
NC WallContrmrFer�•—��meia�•-" / !!J �'
2 � P
FROM TO RU THICKNB311 MATERIAL
COmpanyNeme ' ft♦ r� in. �j'
26.7NN8lEC�ORTIIIBIIQG Seeri�lelaswl-I
2.WeR caustrWAORPera it& 03 9 13 2 ,- 2-07-0 FRona I TO I nLOMMM I MMMENWM AAA
List all alrpllcublewatl construction permits(i e:UiG Coumy,State,y�Farre+etG #t. � in.
3.Well buss(ehe&well trse): ft. In.
L
ns
cipaU blio ft i uCM EMT
o
M(I3eatinglCootiagSupply) Wdential Witter Supply(single)ommmidd DResYdendalWaterSupply(sbared) IS GROUT FROM M BE43 &AMOUNT
rtoawatePsupp(p Well: "/ o c PoJ,u�
. Monitnrltig may � � /
I jec[ion well: elf
/c[_C
- AgaiferReahatge �Groundwati9rRcmediation
Agulfbr&orageandF=ovmy BADIDt vBLrAt t ig
FROM TD 71UTi{RiAi. SMPLAt�rP1ldS,rHOD
AqulferTest �5tomrwaterDraiaage .
Brpe[lmenw Teftalou DBasidenta<Coidrol 8:
Qeotbermal(C1medinap) DTMcer 2D.DRU�1GLflG at�ehsddltiouaIstuxLsif
Geothcrmd eatiflg/CoolingRetam Other Iaiauaderg2lRemaiis) FROM To n x color rx siae.uc
4 Dafa Wells}Completed: -r '2?��reli ID� �• � l�a G�-
Sa.WeRLOMeon• ft. .
FaeflltylOwnerName Faci7ityM9CIfagpVmble) f f.
AhYsieelA)ddres/s.Ciq,andZip 2�5�•��— ft; R. 20
COUY PercetIdentificationNo.(PII3} r.'.;"nc- tv<.v�t,gy
Sb.Latitadeand l linde in degrees! "" ^,t+i• ( i'j7 i
�$ mirtirtr=slsecoads or decimal degrees:
(tEwaIIBeld.tmetaulongis stl�cient) 22.Certification:
f /
6.Is(are)thewell(s) ermanent: or OTemporary sijaw0fomffiedwaboaer Date
By sfgnfng rhlsfarm,I hereby ce V Iftar&a wells)was(wax)um wwred fir amardanee
7.I&Wsaregairtoanezistiagwell: Dyes or at T,W With MAN=MC MOO arIANCACO2C:*2W Wag ConmuctiartStodiv*cmddwa
ffrktslsareipol,JWoutl om Well eonsRucriontnfornuulo�ondeapfafizrhenoumofthe copYR Abre=d�beenprmMhatadwweUmwe;
repab•mder•#2reraarlsseat7oaarontkebacl�afthsfmm. �.SitEtliagttamarSdditfba�f'welldefaiL�
S.For GeoprobeMPT ar Closed.Loop Geothmm d VVellsbmftg the some You may use the buk of this page to provide additional well sibs details or well
eonshvction,only I GW-I is needed.indicate TOTAI,NUbMER of-wells MuMatitm detaJl&.Youmny aho attach addItiond pages ifnetle5 my.
driNed:
S�tthl`t°t' T INQTRIICt';(bjy$
9 Total k,vwell
egs below Iand smlfat:e:
F �,For Ali Wells: Submit this form within 30 days of completion of weu
orm�ttTptewps W Ust all depths tfd�eren t{example-3a t)D'cmdZ®I OOry coashuctiontolhefullowing.
10.Staliewaterlevel below mpofcasingr (£f.) DivlslonefWaterRemiurces MoramtionPrncmingUzd%
Iju�level is above Casing,We as" 1617 WallServlce Center,Ratetgb,NC17699-1617
II.Roreholediezimter Y`� (In.) .
I' ?rib.B Meeting Wells: Tn addition to sending iba form i o the address in 24a
12.Welleonskmeiiionmethod- ���"1 above,also submit one copy of this fam within 30 days of completion of well
(Le vjM Tabu.mbl%dkedVmb, of conshuetiontofhafnowing:
MUMFaR�Ftla'ER$f3P1'LY WELL9 ONLY: UM of WatarR s efflnm ,Vndermandbdeetinn Canh.,l psogmm,
I63GMt�l�ervt�ceCentur,�aletgtl,NCx7699yfG3G
13a.Yield(gpm) Herbed of t �d h 2Ac.fiir Water Sunoiv&�i>tecelon W�nc. Ta addition to sending fire form-to
13b.Dishfiction type: ( �7/{1 gmomb l0 the Seed) above; also!submit:one copy of this farm vAdkin 30 d of
ou I cc completion constnItim La tie county hed&department of tlm e"y
FaffiGWd NorthCatoimal?epaimneatofBavlronmental II Quality-Divistvaof WaterResout� Bevisad2-22-2oi6