GW1-2022-09070_Well Construction - GW1_20220923

Jan. 29. 2018 10:58AM Env. Health No. 6711 P: 1
WELL CONSTRUCTION RECORD(9W1� For Internal Use Only:
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FROM TO D151RIPT10N
WdlContraemrName 2 I
NC Well Coffin or QtrifirAftn Numbe�r�7DIkTE1t Ci1SLYti:fioirmi —e8- :O1tE1REIlomoo
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FROM TO DIAMEr6 THtt9Wf33 aiATERLIL
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/ -> > �� RM.INNER.CMIN OR"' .11 ttiernidl:ctwed 16 ' 2�.
2.Well Construction Permit M. 1 S`/_ FROM -to 01AMCM ifttcfa�s M.URL'L
List-It appfica6le-17torutnrat onpenrdts 0.e.UIC.Cotmry. ,.&ot Variance,ere)
3.Well Use(eheckaell use): n. R In.
WsterSapplyh ern
FROM TO nLM2iCA SLOTSUM Tn CKNEss MATERIAL
_Agricultural Mmunicipal/Pnblic 0 ft. ft. +a.
Geothermal(ReatinglCooling Supply) Olkesidential Water Supply(single)
_IndustrieUCommaxial QResideatialWatei3upplY(sha[od) -.8GROIIT-a-= xM1v:-! '- ;,,.I __ -.•-• _:,s._.�
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Irrigation FROM TO MATERIAL IMIPLACPMEN_T METHOD&ADIOUNr
Pion-Water SDP*Well 9 n. ft. � 'M.
Monitoring Recovery V rt. ft.
Injection Well: R
Aquifer Recharge Groundwater Remediatiort
Aquifer Storage sad Recovery [)Salin4Bauier -FROM tD/Gtt�3BL"P.1 ��L,'- Fc=I EMIAMMENTWIMOD >.T:
_AquiferTest -[)StormWaterDrainage f. ft.
BxpetimenfalTechnology [)Subsidence Control n. R.
Grothetmal(Closed LaDP),. [)Tracer 30cD t;Is1G eudlfiukei&fiA fil rT(i Kiits
_Gwthambl(Ilumti Cooling Rettur Other loin uadertg2l Remarks FROM To DESCRIPTIONadar,bsrdnc,seWm�k, mac.)
O IL O It AV Cd C/
d.Date Wallis)Completed:LL• .3_�l well ID# V ILCj ft. aC
Sa.Well Localio/m h f y"
O Il+r rrO�H lcfy a it.
Facility/Owner Name FacdityIN(if opylicabla) n It. Q ;• 2022
lay 4^ 44tone,, 91,_14rio2 POW
h t -
Pltysind Addeets,City.sad Zip - 1177iri:a= .;• � �,.,-> :.: n;,i
County Pafealldedweetiao No.(PIN)
Sh.Latitude and longitude fit degreeslminuteslaeconda or decimal degrees:
(if"[field.
one tadloongg is aatficient) Q' / ! 22.Certification:
6.Is(Are)the iyQs)10Permanent Or Temporary Sittnture otetrUed Well Connector Date
By'Wng ddr J6rat 1 hereby eer0,6•Thar the vdl(s)nor("m)totanneied fi omotdnam
7.Is ibis a repair to an existing iva. Oyes or -N. with ds f h'CAC 01C.0100 ar iM db1C 02C.0200 Nell Coartnrerton Staadorob and that o
I(fttis Is wrspal,Jt0oraJbmwtwdi eonttrvcfionlnfamation and erpfaot the nanny ojthe cappojfhts mend hat beenprotvded to the irell owner,
repmr„rrd�r�/Rnra.Er lemon oroAthe boetaJrhlrjara, 23.Site diagram or additional well details:
8.For GeoprobeMPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or.veil
construction,only I GW-1 is needed.Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages if neeemary.
drilled: SMUTTAL INSTRUCTIONS
9.Total well depth below land surface: (h) 249. For all Wills: Submit this form Within 30 days of completion of well
For mulnple weft 1rf oil drpdu;JJ cram(eminpfd.3(2W41% 2@1100�')j construction to the following:
30.SMric water level below top of easi0g: Division of Water Resources,Information Processlug Unit;
gwarer leuet it abmr caft we"+" 16171Mait SeMct Center,Raleigh,NC 27699-1617
IL Borehole diameter (In.)
A d J 24b.For Inleetton Wells; In Addition to semdntg the farm 4o the address in 24.
12.Well construction method: � a Y' above,also submit one copy of this form within 30 days of completion of well
CLQ augur•roomy,cable,dmd pusl;eto.) COn9trUrdiOn t0 the fotiowing:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276991636
13a.Yield(gptn) Method of test 0. 24c.For Water SunDty&Injection Wells: In addition to sending the form to
the address(es)above,also submit one copy of this form within 30 days of
13bb Disinfection type: 1 r Amount: C� completion of wall construction to tits county health depsnmcut of the county
where constructed.
i
Form GW-1 Monk CamlioaDepaetmeat afFsv mnmeatel Quality-Division of Water Rwouires Revisod 2 22-2016'