GW1-2022-10219_Well Construction - GW1_20221111

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WELL CONSTRUCTION RECQRD Fbr ttttnxtmt vse taNlr: '
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1.Well Contractor Ieifermadow
It WATER ZOM i
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we"Co"butwWmte p tt 1 #0 SHF.LI.NAS r e.t.�Y
Ale jAic a.5 Ste- A Ave n l fo & ateb SUES -AS
NC Well Contractor Cettideation Number FR URdTER CAttii4Q ! etd ion Hs e
FRO TOI-DIAMIUM TMCKNM MAT6RiAi
Comparw Name
FROM TO I DIAMMU I nftCKN= I MAT
2.Well Construedou Permit iy: Z ft. to is
List aft trpp/laable WdI pe:tnita(lal.CMly.Stare,fa►wee,howflo,elc.) a a, r6
3.Well Use(checl<well W): SMIM
�leher wft. TO I a T SME
i]AgEeWMI OMtulicipelftbnfc 70 /dQ
GOcod1cmW(Hcstin&coolinb 6"y) gdtosidaitio!Water S"POY(sine) iR L
C1IndusuWComrnareia} OResidential Water Supply(shared) MM A c srrr M&&U%WffAMVVffV
Obtinstion © ft, 24 rt 1r4
Nowwater supply Welt- fL A
Omonitoring C7Recov
Injec"Ou Wen.,
❑Aquifer liege t70roundwater Pimediation 1 VBL PliZ
PROM I ro WM AL NAlPLACE7tdBNTal1"17rOD
Mquif'w Storage and Recovery OSalinity nalrie!
OAquift Test OSttxmwtltar Dr"ge
0EXPaimeaw 7lxhnologq 08ubsidetnce Control
2U. t MG LAWMataeb ttomds ly
11300htalnal(Clow imp) ©TtaM FROM To I ouasua 11ON rotor l+ eia
00tathannai 11 0o!A Befoul 00dwr aln under 4121 Remarks p $. Q R.
4.Date Weli(s)Completed:/OA220 Well 1D# /4 iw C4
T tt L rs 4N.
Sa.Well lmcadoIC nD er. ft.
n es p: 014j,..
F4Mll y/OwaerNttme FacUlty ll'Mi(U'appikabte) R ft.
tmyAke!AddrosD,C&Y,�a� al 9If'1f' zL
CoutltiY Pareo!IdeMtfieatton No.(I
9': P -v
Sk Latitude and L qg tude in degreWndautealseconds or ded mai degrees: 27 Cel7lfiesdom: GVVQi IIOG
(ifwell ECK one tatllong D suffrelent)
31s. 08 438 N -74.`4S (a ;L w 1_t.rJa9-;- i /o/fit
sio0we ofcort#iad wen Conuaowr wto
&Is(are)the wall(s): Miernmeent or OTemporarg By arguing Ab form,1 hereby cer4&rho tke xell(a)war 6wpv)oonrft teed M awadaace
with 15ANCAC 02C.0100 or 1SA NCAC 02C.0200 Well Cmt*udfmi StMAV&mid prima
%L this a repair to an exk tq well: Oyes or copy olp4tt record Ims beenprmlded w rha well owner
Ifrkta to aarpalr.jrJlant 4rtmva well eanstrpettontrt/arnrotion�d explalnthe mrttnlr r�tka Z3.She dla$ram or addltMDel Well dttalla:
n FIV&ovral"02t,eMonb a wdon oron eke Aaekq/p6t+form
You may use the back of this page to provide additiaatal well site details or well
L Namber of wells congtriicVA, construction details. You may also attach additional pegs if necessary.
FormW4pk lVeaton or non-wmera ffly welkt)IVLY with the same cwv&uctrorp You can SU11M1TTAL INSTUCTIONS
snbMit ow fo m.
9.Total well depth below land surface& //G ({L) 24a.For All Weps Submit this fnnn within 30 days of completion of wen!
Formulo*wags oar opdepka jfdWg ram(exaerple-SWO'mrd t@1o0) construction to the foilowhw.
I
t0.stack water I"below top of easier (tit.) Dlvlelon of Water ResoDrCM Infornmdon ProM tug U014
9'winw k wi tr above 1617 Map gavlae'Center,Ralelgb.NC 27MI617
ti.Borehole diameter. ��R (in.) 24b.EM inleadnn V�Q ONLY: In addition to sanding the folml to the address in
A ��'�— 24a ebmre,also submit a copy of this form within 30 days of completion of well
!s wen eanseroctloa melbod: .`L 1' &,,r444 conmIction to the foUowing.
(w.sugar,MWY,401C,direst push,cw.)
DWM*n of Water Resources,Underground Injection Control Program,
FOR WATER StWLY WELLS ONLY: 1636 Matt Service Center,Raleigh,NC 2709-1636
�j p T 24L For Water Sooty&Iaketx n Wdb-
13e.Yldd(gp01) Q�L` IYIEWodOltCafJ Also submit one copy of this florin within 30 days of completion of
13b Dlsiafection type: Amount QL � co cdon to*a county health depmuncru of ft county when:
conshucted. i a
Parm Gw•i North Carolina Departr>leat of Envlroament and NOW Resources—Division of Water Resamnea Revised August 2013