GW1-2022-07234_Well Construction - GW1_20220805

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WELL CONS UCTIONRECORD Q Iz For% uSBOnly.,
1.Welt'Coatt-raachar3nrorm oon:
I4.WA7ERZQ11NER ; • �.,
Wau CoubdorName FROM To DESt ION
/� _ It80M Td DlAMEM TA[CKNBSB NfATERUL
f.. >�.« ����'O[S J rLC.. � 6 .f� .ID.
Companyl3ama 3 AOX-2-1
1t;.li!fNERC�IGDRT[IDING them�l bsedd
2.Wen Construction Permia..06%) -FROM To I D14MOM I
L15141 4ppliCaW W411CaMIMctlonpMOS(19.WC,Carmty,State,Variance,eft) ft. f f.
s.WeII use(Checkwell use): In.
Water Supply Well: 17a
ionPROM T8 scaTst� . ►T$rttns
Agricultural :,.,RMuufc6iYPubllo Q fr. tr: ram.
Oeothermai(Heating/GaolingSupply) ,EKMAeatidWater Supply(SW e)
dustdal/Commerciah DResIdenddI Water Supply(shared) It;t�tOl7T
Ibulgatfoa FROM I To MATERUL- I EMPLACi MMr OD&AMfff
Non•WaterSupply WeII: tt: ft.
. Motlitrlring ewers► . � � /
IMeetian WeII:
. AquiferRe�ge -: �CuoundwaterRemediaticn .Ss:SMIDJGBhVl;LP CS iy lteahI -
RqulforStaragtiandRecovmy MwriityBanicr FROM TO :ure prey_
EMFLA�NPrMSrROD
Aquifer Test .. �Stomtwater])reinage -
Exptuimental Technology DSubsidcnce Comroi
Geothermal(Closed Loop) 13TMcer O.DRII�Iei IAG aftacTradditionsis5eetsi€ ", ,;;
(leothecurel Ceolhn Retum Other FROM TO Dsscxu�oN ootor h.nin" sufl/ioek etG.
eatuzg/ g ea�laiaunder#21Ramarks)
Cf
4.1Datewou(s)Completed:- Weilmip 20G ft tt.
Se.WeRLOWdon. &.
FacilitylOnerName FacilityID (i€applimble) % r" ~ti
Ca. 7 ft.
PhysicsN .L�t.wd.Vp '�' • t!Iz fL ft. A i 1 r, 0,'5 2022
�S OH 21.RE31�RIf3 _
County C' Pesat%dectiiicatiamNa(Pil3) intermakin ProG-Oftm Unit
3b.Latitude and longitude in dagreadminoWseeonds or decimal degrees:
Orwell 4(eld.ana>Ulon is su�cieot)/( . `j r- 777,
/40'/0,
LL
6.13(are)thewell(s)�ermanent - or OTemporarg
Si oMerMea en r Date
By signing Mfs fvm►,l hereby cgnyy ffrarft brgs)was fuve)can mreted In acrmilmne
7.1s this a repairto nn esistingwell: Yes or wilt ISANCAC 02C.0M0 orISANCAC 02C.02W Wag Construeifa&andards anddWa
if tits lsasepalr fill outl�awn wattrnnmsralan lnformatfon and eaplatntherraaaeofthe copy ofthisrecardhasbaenp v�Uadtadjawamww.
repab•underd2J remarksseetlon anon ikebackofthis form. 23.Site tiie�ar a$didiol�l welldefaits:
2.For Qeoprohe/DPT or Qosed-Loop Geothermal Wells having ihessme You may use the bad:of this page to provide additional even site details or well
construction,only 1 GW-f is needed, ittdicaw TOTALNUMMER of-wells common detat75 .Yon may also attach additional pages ifneeassery,
drilled MM MTTALINgMTTf MQN&
9.Totei well depth below land surfacer (fb) .241.For All Epells: .Submit this fort within 30 days of completion of well
FormulNplewetlsllstalldepthsffd went(example-3aL12o0'and2QaIUD5 consOctiontothefollowing:
1O.Statie water level below top of casings 2 {fC,) DIVNon of Water Resources,Iuformation Processing unttk
Jjwater level is vbove casing,ure";" 1617 MailServlce Center Ratefgh,NC176991617
11.Borehole diameter. MR.) 24b.For Juteetlog Wellst In addition to sending the form to the address in 24a
12.Welleonstruction method: do&C above,also submit one copy of this form within 30 days of completion of well
(ie.augmrataw caW dk-tpmk eta) coashructionto tefoIlowin
Division of WaterResourew underawandWection Cant mi Pro
FOR WATER OFFLY WL+' W ONLY: 1636Mail ServiceCenfer,Ytel�glt,NC�'1599.1d36 t
13a.Yield(gym) Method of test .R�/��J h Lyr�; %24c.Far Warner sD>jDly&>(gyer6aa Welts: 1a addition to sending the form to
the addresses) abatre;-ab' submit one copy cf this form within•30 days of
13b.DisrDfecIIon hype: Amount:���e+C is completion of well ccastnictioa to the county'had&department of the county
wherecanetmrtPn +
Fom►GW-1 NorthCamliaaDapaameatefBnvlroomantelQaatitjr-DIviaioaofV[►aier !Rescnc¢es Redod22?2016