GW1-2022-09898_Well Construction - GW1_20221028

82M22 7241 1 P.1
Feb 16 19 05-Ap Cl,arwater Well Drilling �._._�wn ''
WELL C N TRU TION I2ECO . GW�1 For in(emal Use Only:
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1 ,nntrattar lnformatlo -
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�•V V�' UROM ft.
Tb
M.tN11FR CA91NG OR A1f61NG drorrarrlctwed•itw NASAL
70 DIAMCCEtt TAIC1tN6S5
2.Well Conetrnctien permit Lht rill a iicnblrr wall ewiriteddn pt<n+ttrt p a till'.Canary Srarg Yartrotcv etc)
rr
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S.Well lice(check well ust:):
17.5 EN n AMrt'r6�t ArAqfflm 'ntrCKN�83 u7&Rur.
Water Supply Well. FROM to
AgricuiRlrnl
MunicipnVPubec p �• � °1
Geothermal(1•Ieating(Conling Supply) [311rsidential Water Suppiy(sfigic)
rndusifiallCommercialResidential Water Supply(shared) 8 OUT
-t, TO
MA'r6AtAL 1LMt7AC &•iT�t sr77tOr1&A<•rO11NT
Irrigation ft, fr
iVnn 1�ntt;rSapplyYiell:
Recove U, fc
Adanitatin �'
tnlN:ttcn Wncchell: f4 R•
Aquiferar a E30roundwater Remcdiation
6 C..+ 19.SAM1It;itAVELFkCit ifa ble
Aquifer Storage and Recover}' [3,winitg Barrier FROM To n, nrK MAL 1rt�lAC8M11• BtiT>titCflrOa
Strttmwater ranag ft
• Aquifer Test � Die � ir•
Experimental Teehcology DSubsidcnw Control
Geothermal(Closed Loop)
[)Tateet 2&DRILLING LgtC atlJoe
TO DPS mkrr• rras•drHasktFPa Aratn siu,qc,1
C:cothermal(tleatio Cooling Return) Other( lain under 921 Rcmprics} PROM
n, f6
A,Date W41(s)Completed:,_,___---_.__._._.Well 11)11
Su.WellLncntlon: r It.
1%aci{ih'!()nnctilamn F i►Y lf)H(LfaMlicablc)
Shflre, 0r •- Ib +�
r n. OCT
�Physica{1�ddr�cs,City,��Zr�� � W _
z1.tsEntnRtcs
d �'f ]rt•I Vil�i+��l f irk:�74'e�:�r�..Jl tirNl
Caunty Poteelldentiifcafion No.MMI
Sh-Latitude and fong➢tude in degrmimhntteS/secondsor(lceimnl degreem
ffwelificll,onalaMongiasuilieicni) 6 t 12,CE fiCAti ,
loll t 41 5lO ova •g W tr�t�� -22'ZZ
signora . rc Will cantraetor — Date
fi.15(arc)the well(s) ('crmaDent or ©IlempnrAry
LiP Btf.7lia$rtt1A'i%�r'm.! anurraertvt/n au»rrinnce
11%thlt:a repair to an existing wen: riYes or 191No u�rJr 15a tiG'aC a2f..4lDD ar 15A XCAC 42r:.P200 W!l[Catts/rnetinrr Siatniardr rmr!char rr
!J'ddr isv rcpafr fill nutl�fnrvn till coastruuJmt irnnnaliaa mill crploin the.atria nrdta copy nf11r.+.c rccnrcl has ht+9t pMldderf In rite a Cif mv77er.
1-:pair under A21 rdmnr$r attar ornatltc lark-of riots farm. 23-Site diagram or ndtiidonal Wall details:
R.For GeoprobelllPT or(Iresad Lrutp Geothermal WOW having this same ),ou may use Ilic black of this pegs:to iwovide additionad well site detl&M or wet)
nmsiniation,only I GW-1 is needed. radieato TOTA.)NUMBER of Uurlls
construction details. You may also aitaoh additional pages if nt cessety.
((J � Cnnwi /�l( 11� 11f��1115`
9.Total welt depth below land surface: `• ( ) ?121•L BOr Ail Welts: Submit this form within 30 days of completion of well
l%nenrrrlrlpfcwrtlslixralidtprlurfdrllcrrnr(rsmrmh-d�70�'and tnA) cnnxmrctiontothefelloteing:
In.Static water level below top of easing. (ft.) DiViSinn of Water Resources,lafnrtaation Processing Unit,
IfrraterAm!!isatvrretaxing,me"-" 161711 ail Service CeatcnRaleigh.NC27699-1617
11_%reholedinmeter: (in•) Zjh.Fnr lrrtect;On WOlirr. In addition to heading the form to the address in 240
ngove,also submit one copy of this form within 30 days of COmplatitm Of well
Ix.Welt construction method: construction to the following:
fie.auger,sitars.table,direct plait,tdc.)
Division of W Ater Reataltoe.9.Underground irjeztioA Control Program,
ir(51%WATER SUPPLY WFLLS ONLY: 1636 Mail Service Center,Ralclgll,NC 2709-1636
131.Yield(gpm) Method of test: 24c. I r Water Sandv&1akcHon Welk- In addition to sanding the form to
Me addresses) above, also subatit one COPY of this fort within 30 days of
13b.MOnfeetion type: Amount: completion of well construction to the county health department of the county
whore constmcted.
Form Glt;-I rfnrrl,l.atnlinuAcpnrtmene ot'i;n.-7ccinmcotal 4nali tg-T>i•nsrnn at'Water Ravann�c Revised 2 22 2a{tS