GW1-2022-09079_Well Construction - GW1_20220923

Jan. 24. 2018 10:58AM Env. Health No. 6711 P'. i
WELL CONSTRIIC'PION RECORD L l For buff w Use only:
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L Well Construdton Parmitff.,
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3.Well Use(theekw A use): _--
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WuerSuppiq well, --- - - —— i-
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Geodamai(Ilefilbe cadling SUPOY) m w Water Supply(sho) to IL in. -
_btdustrieilComtturaiol 0Resideadal Water Supply(shImd)
1 ' lion of MATUM D&.
Dion-Wafer Supply Well t3 Q G tc
Monumin8 DRacMR. R.
Ipiec n ell:
_ AquiferReclarge ©GmulaiwatterRemedietial _ - .
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Ag fifer Storage and Recovery 13SalWW Bonnet TROM Tous_
_Aquif::rTcst �Stotmwattrlhai1f8g8 M R
FacpaimmtelTechnology f3Sn6sme econnol IIL
Gcothermal(closed L"p):. �]7lreeer 3TO loom
Qeodleralet c1�CoolmgRetlaa O =W#21 Rammks wan
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d.Date Welts)Compkted:,f-2-a, wtu m# _
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Sb.Latitude and loWmdeiD degreuWauteducands or dedmai degrees:
(ihvet ftKaoetadlmlgts„dfioivatj /o S` 22.Cerlilleatioa
6.b(are)thewell(s) Peymment or Temporary 9ipulmeo cniIIadweIIcaaaactgr mte
By AiSdq&a/eft I henry CVO umr d+e Vwx)rm trm1 eamwM rd 0r aerambw
7.b fbb a repair to an esisting well: QYes or ON& A MA1VCAC 020.0100 or 13ANGC 02C.0200 f➢idtContrrMORA MW Dad dmr 0
#rWsisvmpah,parubrowiwec&wn win homam6onadaep/am&mo&wgib aopoldaUmomdAoterwprovf*dfo VvWowxQ
Mp jrWRW M71 srnarlr uaron or0n der bOd40f tfema 23.Site d,sgraln or additional wA dculb:
S.For GeoprohdDPT or Cloaed•Lvop GeotLermal WeAs haviDg tha soma You m3ty am the bwk of this page to provide oddido al yell 8da details or well
omtructioa,ally l GW-1 is needed.bftte TOTAL NUMB of swells eonsbtccGondetatle You may also attach edditionat pager if neceswq.
dnlled: RX
9.Total well depth below bud suibm YS �•) 2aa.for all Wells~ Sdmdt dtis toner widtin 30 days of completion of well
Fbrnaa>rprewe&1watiAPul -e-d(e> 3P00'sd20IW) eo,amtkm(D amMowmx
10.Static Crater(oval blow top aftedeg: t�d (Q) Dttdaion of Water ResoumM IDformalton Proeeuing Unit
lj+rorerlerel traboreemi0g cite+• 1617 Mil StMoe Ccbtcr,Raleigh,NC 27699-1617
IL Rambols diameter. Od.) 24L For inl��VeUa; In addition to sond618 the Cmm m dw addrm in 74a
dmM atw mbmit one copy of this farm within 30 days of tompletion of well
1L WeR eonsfraNloh method: (� calsttactiontp tllefoltovtiog
(ieav�gCLnmry.r�btc,rruedpusltetn) -
Divhdm of Water Rdooreea,Uddetgmdod Injeeton CosatI Program.
FQR WATER SUPKY MUS ONLY: 1636 Mad Service Cankir.Raldg%NC2709-M6
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130.Ykid(am) Method of test: r a4e.For Wafer Bounty mr inleetton Wel1� in addition to smdLtg the form to
the addtess(m)shove,also submit one copy of this Imm within 30 days of
fib.Didnfettlon type: Auloum: a G s co"Ietlett of vall constcution to rho comw 1+eai1h 4artmmi of dm co"
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FmmGW-1 Najd. D � m�QwLpr-DivisaaofWotaltc+omees Ravirad2.22-2016'