GW1-2022-06750_Well Construction - GW1_20220603

FELL CONSTRUCTION RECORD UQW 1) For kdernalUse nly..
I-W)f ContractorInformadon: ;
1+6 WATERZONSS
Nell Con`trec NNeme FROM To nI ON
f6 ft.
we Wall Coat.mmrC-eO.2i-M—.ha ^1 -
FROM TO DIAbM TfIICMMw
9ft- W ft. in. 0-
Compeny Ntuna
M.MN13RMENGORTUBING dosed-1
L Well Construction Permit: MO—M TO I WAMMM I MHCKNM bUT991"
Liar all applicable well conatntction permits(i e.Uic.Cotmty.ftre.Ymfmrce,site) ft. ft. in.
3-WeU Use(che&weft use): fb ft. In.
waterBnpplJ well.. FROM MSTIrU .
Agricultural Q fL I
Geotherraf(Hmdngtcootingsuppfy) M%�ideatialwatergopply(single) g, s. tm
ustrial/Commercld DResidendal Water Supply(shared) 1&QROOT
IrrfItation. FROM TO blATSRiAl. CEIMM OD&AMOUW
Non WaterSMIy Well: it. Wr ft-
Monitnrmg &
hdecHon went f�
AquiferRecharge �GroundwamrRwnediatioa
Aquifer Storage and Recovery Ownfl cruder FROM t TO
O llt<ATIIR[Ar, snu2ac eec'nlBrsoD
lAquifer Test 13StonnwaterDrainege &
Experimental TcchuoloV DSub3idOnCOCOnftl & [t:
Geothermal(Closed Loop) Tracer 2U.D LOG aftacbadditionalsl wisif
Geothermal Coolie Remy Other Iainunder621Remarks) FROM To DmtsCttrnrrort color e,a
it. ft:
4.Datmi Wens)Oompleted:&14 Well cop -
go.Weft
Locafion: R•
FacilitylownerName FacilityM9 Cifapplirable) ft. J
LI,9IN �l� 11/G 7� 5 .nti 767"( f<. ft.
Physfod Adtimm.City.m ci ft ft. ft.
l��?Nlrl /(•I�� 2bB81ViABfh3 unr;r ,r1 JUL
cout9 I?ezcel IdentiBratioallo.(P� �' t
6b.Latitude and longitude fn degrees/mlartteslseconds or decimal degrees: tA
(ifwetl field.one latllong is sufBclent) 22.Cartificatt
s.Ware)the wells) ermanent or Temporary S, o Culled W&Contractor Dais
•" 4 stgnfitg ftfam I hue y we that the va(s)wm(mitre)aouwucted 1a arcm*=
7.Is this a repair to nn exisftwell: eyes, or ONO wlth ISANCACO2C.0100 orlSANCAC 02C MW Well Cotutractimt Stm,dmds anddw a
if this Isarepair.fill out known well constrm:don 1njbn=don and asplakuhe mews ofthe copy of0d.;mmrdhasbeenpro7ldrdto the well comer.
rep*zutder#21 remarbsecdon or on the backofthis form 23-Site diagromaradditioirai well detai'ts:
S.Pbr C-mprobrJDPT or Closed-Loop Geothermal Wells having the same You may use The back of this page to provide additional well site detddis or well
construction,only I GW�1 is needed. indicate TOTALNUbMaL of wells conMedon det�s..Yon may also aftadt additional pagnes ifneoessary.
drilled' —f—
SUBMEMAL
9-Total well depth below land surface: l 7� (f�) 24a.BE All Welts: Submit this Rum within 30 days of completion of wen.
Formultlple wells list all depths lfdfffferu(emmple-3 a@2W'mrd2@1005 constryctyonfothe foIlowinF
10.Static water level below top of casing: 42,6— (ft.) DlvMon of Water ResourcahIdonnadon Processing Unit,
Ijwater tevel rS above taring.ure N-°
1617 Mali Service Center,]deteigb,NC 27&99-16i7
IL Borehole diameter: (ia.) 24b.For infection Wells: In addition to sending the form to the address in 24,
IL Well canstracffian method:- eve.also submit one copy of Ibis farm within 30 days of completion of well
(Le mom rotary cabby,dPrectpasts ft) Construction to fie following':
FOR WATER SUPPLY W&W ONLY: Didsion of WaterRmimm.Undwgnmand Ilrjectfon C=bfti pl g,,y
1636MailSUvtCO,Centw,MOWN Z769NI06
13a.Yield(gpin) Method of test: 24c-For Water Surtnly&�inietam Weft Ia addition to sending the form to
the addresses) above, also submit one Dopy of this form within 30 days of
13b-Disinfeciton tdrpe: Arno completion of well emlsfrCtion to the co>mty health department of the corer W
where cansuucted.
FormGW-1 NomthCerolutaDepanmmtof8nvtmnmaotelQueSty-Div)siaaofWaterR�am> a Revised2-22-2A16
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