GW1-2022-07165_Well Construction - GW1_20220729

Jan. 29. 2018 10:58AM Env, Health No. 6711 P. 1-
WELL CONSTRUCTION RECORD(GW_12 For Internet Use Only:
I.W 1 Cootracto Informallo�p
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wellConndsiiName saOM TO DESCRIPTION
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NC ell Cofilmdyor CentfirationNmntrer q4'1--gIkIE1lCASM'foe29Riiifdifells:OIt fir"IiihrMbMom.:. M:
`i FROM TO DIAMErE TH[C70YES9
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L J 7 7 .� 3' aIrtEizea slrtao �ttiDttrt�: tha,u+teror: sdaoo {f..6{JfGYK:'Fr^C.
2.Well Construction permit#: FROM To I DIAM9171t I TMCKNM I MATERIAL
list all applicable well eorutnte ioaoontts(i.e.WC.Carry,Stare,Variance,etc.) IL R. la
3.Well Use(checkwell use):
i1rrigation
ater Supply Well! �.IZ:st?REBeI:@`��-��=�.��;��•W,� �� W,.:;=.�:cz:F�_•'.ems�`-_r�u,
FF y %I To D arsxt SLOTS ITE TUICIMUS MATERIAL
Agricultural [oM ipel/Rtblic 0 R. R,Geothermal(Reating(Cooling Supply) _ResidentialWater Supply(single) R. fL131taidentiai WaterSupply(shored) FROM To MATERIAL 1 VVtr1ACEM MErIfOD as AMOUNT
Non.Water Supply Welk Q re.
[Aquiftr
oring ❑Rerave R. R.
n Well: R
er Recharge [jGmundwnter RemedietionerStorageandReeovery CjSalinityHarrier FROM TO MATIM" ACRNIMMMOD
Tat dStormWalerDrainege M 2imental Technology Subsidence Control m R.
ermal(Closed Loop), C)Traeer -s•20D GI:t♦G eI&'W'add1t16TMi:lliA—WR)se'iQUA °ermal Henting/CoolingRetum Other ex lain under#21 Remarks IIROM To DFSCHUFFR)N cater,ee,dnez%NIMuac•1-•--mtnsQe eu.
4.Date Well(s)Completed:7 0?� Well ID# 7p n ? n
Sa.Well Locations >S R y�ft. 6
�h-„/Prdifit�� 3aS 9� n R.
Fact'litylownaName Facility
IDA(ifnppticable) fa n. a
tt. n.
lilt
Physm Addtest,City,add
2 n.
Count' Pascol lden0cadan Na(PIN)
56.Latitude and tobglmde 1n degrees/mioutealseconds or decimal degrees: C
(it'well field.one IsiflanIt is sufficient) 22:Certification: -
��°�lG N � , � w o?S/J 3
6.WIN the well(s)oPermanent or Temporary Sitpraruse ofeenified Well Contractor! Date
By signing dr;t form,l hereby certo(her the wdf fr)ras(were)eontmred rm aacordaaee
7.is this a repair to an existing well: Yes or E)No with 1SANCAC 02C.0100 or IJA NGfC 02C.0200 Well CoAnnieaon Stark*?*and that a
((this is it repah,fill ota kwwrr wd►omtruulon fro madan attd erplam the muff#Vf1he cap)•ofthis record has been prorrded ro the well owner:
repair under 871 remmrfs section ar on the bad ofrMsfonn.
23.Site diagram or additional well details:
&For Geoprobe/DPT or Closed-Loop Geoilwatal Wells having the same You may use the beck of this page to provide additional well site details or well
construction,only I GW 1 is needed. Indicate TOTAL,NUMBER of wells construction details. You may also attach additional pasty if necessary.
drilled: 1� ) ` RUBNUTTALINSTRUC.fIONS
9.Total well depth below land surfaces 6 d / (R•) 24a. For All Wells: Submit this form within 30 days of completion of well
AVMirlaple wefts list off&pdu tJd ffmat(esdmpld-1@2M'awd 2@100') construction to the following:
10.Stark water level below top of easing: ([t.) Division of Water Resources,Information Processing Unit,
/frsarer lew/is abot-e mans rise-+^ i617 Mail,Service Center,Raleigh,NC 2709-1617
11.Borehole diameter: (ln.)
24b.For Injection Wells: in addition to striding the faun to the address in 24a
12.Well construction method; AV 9Aabove,also submit one copy of this ib within 30 days of completion of well
mh
(Lc mgcr,untaty,cable,&=I pusi4 eto.) '�� construction to die following
Division of Wafer Rcsources,triderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mad Service Center,Raleigh,NC 27699-1636
c
139.Yield(gptn) 3 Method of test. . 24c.For Wafer SunDty At Injection Wells: In addition to sending the form to
the address(es)above, also submit one copy of this form within 30 days of
13b.Disinfection type L Amount: ���✓ completion of well construction to the county health dopanment of the county
where constructed.
FormGW-1 North C=si=Dgwn*teat ofEmrimdm atel Quality-Division of Water Rcmmms Revised 2.22-2016'