GW1-2022-06497_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD fGW iZ For Intefnal Use Olily:
1.Well CoatMOlMrInforma k fl/n'o�n:/nJ�� j
�0 n (�T 1'C.+1 2144LWA7M ZONES
Nell Conti Name TO DIK RWMN
3 ..V�90 er,
NC Well Coetreomr Cectifioetim�ivmmm .
QQ A Q F
l4v/Q 6 1n'1,iLC- QT S �✓1 ! FROM TO I DID T1 UMM MATERIAL
CompMyName ft. in. stop--21 Jot
1rxDWIMCASINGORTIMM dosed-I
2.Well Cnnmhmction Permit#: FROM To DrAt4MM VMCMQM MATERML
List aliappllaablewall cons/rualonpetwaits(i e.UfC,Comity.State,Yarfiatrce,etG} #t. B.
3.Wen Use(check well awe): ft°
Waberi3opplT Well: 1:s
ben
Agricultural cipaUPitbil0 0 h. M in. aa�► euL
Geothermal(Heating/Cooling Supply) tial Water Supply(single)
usirlal/Commercial [3Residemlel Water Supply(sbamd) 18 t;RtOtIT
FROM TO MATt$tiAL I SMPLACBMSNT ODdtAMO
Noa•WaterSupplyWen: s. pt, 3 ,.
Monitoring JFL ft-
Ig se lon Well: .0 Q
& B.
. Agt+i%rReohargc �GrotnhdwatarRetnediaticn 19 tiANDJGRaI�ELPA
AquiferSMMVandR=ovcry f33aimiwDMIicr FROM To IMURIAL MVMACMUMMS17iDD
Aquifer Test DStmwwaterDrainego ft. ff
Is�ipedmental TechnoloV DSubsidenca cmil of
Geothermal(Closed Loop) DTrac7 2(LDRHJMBLOG(atinhaddidamd8heeftEnecomyI
Geothermal Cacling Retttm Other.(-,plainuder#21Ramarks) FROM To DBSCSIPlY x
D y ft.
4.Dalmwev(s)cngdct&: 3-2 M#-,A 7&Z(,-- ft. ft.
Facility/Otmer23em Fac iWM# ifMVMble) ft. ft.
29 fL ft. s
Ahysiaa/t�Add�ess.Ctbr,andZip �7t� R. ft.
F In
N.t r SO s l 21.Rtihfg$B$
C0u* PtecnlIdentificatiamNa(PII�
Sb.L%Mdeand longitude in degrees/mianteslsecaads or decimal degrees:
(ifwellfield.one laUlongissufficient) 22. on:
6.Is(am)the well(s) ermanent or 13Teraporary Signature ed W Date
By,signbtg this fOM I hereby a:n&that the w4s)tvas(carre)aatrstrtrcred in arrotdm ce
7.Is this a repair to an eistiEngwell: DYes or PTp Ivtth 15ANCAG 02C.DI00 orISANCAC 02C.02W IVen aDngmWonStmtdards and them
Ifthts isampair,fill out/mown watt consrruaion inprmttuionand aplarndwnowrafthe ropy 4fddsmcmdhasbeac prwkW to the wall mvner.
sepalruMder#21 twwbsedlonoron the backofthisform. 2S.Site diegltamoFedditionel van deta!'!w
S.FW t'`,,eop-he/DPT or Closed taop Ceothertnai arm having the same Yau may use tlhe back of this page to provide additional well site detalls or well
construction+only 1 GW-1 is needed. indicsta TOTAL.NUUBML cf wells constnietion detalls..You may also aftch edditior&pegs if necessary.
dritted: SUBIi�IlTTAt,IIB.47'RiTCfTnNs
9-Total well depth below land surfaces S S of completion of well(ft.) 24a,For_ y fls Submit: this form within 30 days
Formuit/piewetslistaIIdepthsiffi est(eaampi¢-3@200'mtdl@IQO5 All We
eonstrucdouto the following:
10.Static weber level below top of easing! (ft.) Dlvtdon of Water Resources,Information Processing Unit,
If water level is above awing,awe.N-' 1617 Mall Set vice Center,Rateigb,NC 27699-1617
11.Bomhole dianleber. /1 (tn.) 24b.For titration Welts: 1n addition to sending the form to the address in 24s
a Wen conshmetion method: )Z—C N above,also submit one copy of fibs form within 30 days of completion of well
(Le.sugm ratary,eaW dinctpssk eta) T CMMhUolfon tD the IbIIowing
DivUlon of WsterResnurew Underground h decftm Controt pa+odw
FOR WATER SUPPItY WEirIn9 ONLY W6Mail su vitcg cgntga,lse*jl,NC Z769xl6m
13a.Meld(gpm) �Z Method of te� ,Q 241—Fir Water snnnly&linleclion Wens• In addition to sending the form to
the address(es) above also submit one copy of this form within 30 days of
13b.DMnfedlon Iype.,—j4xII Amok & Qkglygg completions of wen construction to the county health depadmmt of the county
where constsacted.
Form GW-1 NonhCamliaaDepar�eatoi73avlmnmaotalQmtity-Dhririoaof WavetResontees
Revised2-22,2om