GW1-2022-00129_Well Construction - GW1_20221219

WELL CONSTRUCTION RECORD lbrrmanal u9eoxr.Y_
M&faammnim used farsmglo"nm tipl =%; `
1.Well Contractor Information:
FROM 'N DE5CRIP7'ION I i
NC well Co�meorCatifica6caN®her L4�'01171'FRGISQIG(fir®)ti wblls ORIB�
1?ROM 7P0 DTAMML TE11CO M MATERIAL
c�y� 16.1NNBRCASII�iGtrxTtlsn�lc -- i ": _
� FROM I I DINMEM I ?IrICEPWESS I MATERIAL
2.Well ClIft,etion Pumitk- l z r1/l UII C:. r` tt "Z2,1441,3I P <:i_
Lwaffappl mme wftpaoau Comup Varfmna brJedi=eta)
rr ;n. S 16 rVe
3 wen Use(eherlcwell ese} 17 SC M
WatersupplyWen: IBM TO 'tHINCOMS MATERIAL
OAfic huml OmuuwipaUPablic $.J 7 >z bg
13Geothenaal(HeafiWJCooli%Supply) CResid®tial WataSvpply(sing[e) R i
i3IndusttiaVComnercial Aideatial watersupply(shared) IA GBOUT
tBOM TO MATERIAL EMPIACENEW EIHOD&AMOIINr
Owntion 0,0
t�
Non-Water Supply Well:
O eaftormg Eatecovely
Injection well: 8 S
OCnomndwaWltwInediation 19 SAND/GRAVELPACK tf
FROM TO FMMEIHOD
OAquif-Stomp-dRecovery CSdhAyBurier
OAquiferTest t]Stora wrtaDrubmge tt I.
OBxpedntowl Technology OSabsidem Coulml
2&DRU=GLOG atta&adffdio=lahsetsif
(Closed Loop) OTlacer mom
TO nM�Dnlorr mrortatdom.ml►neit smt.era
munfficanA(ffcsigdCoo' Rrfnm) aOffiw(eKplamrmda#2lReamft) i:. 17 s 54\
fL /C3 -vn
4.Date Wells)Completed: p well 1 ,` ft. fti
Sa.weRLoratiom gv fL Z<(jhl-i 41��.
ices L�-�_ s z g �j firms., �c If--
Faorwowtr %= &
fr
�� ��omty7072
f-
C 1'moel ldmti&®a"a
56:IatitadoaadLangitndeiudcgmes/minates(seeondsordcdmaldrgm= 2Z cpp,.dm 3�Z- •� :^:�,., ;
r-gta
(tfivelltield.one lffi!lang�wffieimu)
r� �`
( / �j"j ` N C 3� t' T F t W
17 Date
SigoawvofCatifrnd WcH
6.Is(aM)the wa(S): ffi-m—'Meet or OTempormy gy g&&fans.,r Hereby cage&w dx,relt(s)ma&=4 evrutrr eted w aaordm w
with ISA NCACOIC_oleo or ISANCACWC-089 Nell Com&=Umrb7armw&and dun a
7_Is this arepairtoaneAstingwel@ OYes or DP;w— ovpyofLwsrecordh-bwapmmdedtothewellowner.
If th[s rs a rrpanr,fell out f amm weg emrmruuLon ioforaratton and apLrfa the rranrrr ojthe
mpairwader Zl ramuirse rma aron&eboctofd&form_ ZL Site diagram or addi6vmd well derails:
You may use the back of this page to provide additional well site det uls or well
L Nunber of wens constructed: construction details You may also attach additional pages ifDeotssmy.
FormallJpkfrJteNaaarnoa-natQsrrpplyvei/sONLYwilhdresnmea�aa.}mrramr �� � .
submit�rfam SMbff PAL IN WCPIONS
I'
9.Total well depth belowlaad..dare: 54 (ft:) 24a.For All Submit this form within 30 days of completion of well
I%ormd plew&lista9depda(fdffaau(c=p1e'3PIQ0'mrd2@1M const udiontothefollowing -
10 Statiewater level below top afeasmg: ( )
Division of Water nProcessiriguniti
Ijwaterkvd&abvw costa&roe'+� 161T Matt Service Centers Rtdeigh,NC 27699-1617
1L Borehole dmmeter_ y l (n.) 246 Far Injection Wells ONLY: In alddition to sending the form to the address is
24aaboM also submit a copy of this(faun within 30 days of completion of well
12.Well construction mdhod: ML.' - IZ - oonstcuctiontoft"owing
(i_a 8.totm5:eabyr-r., tpask en)
Division of Wabv s,Resoass� IIa I aground Iajee6(n ContialPmgram,
FOR WATER SUPPLY WELLS ONLY: I636 DW Service Cent_(t ReleW4NC27699-1636
13a.Yield(gpm) buthod of test CCr� 24c.For Water Supply&Inieection Welts:
Also submit one copy of this form within 30 daysofcompletionof
13b.Disinfection tywIA Lr°u Amount: .( " well conshuc ion to the county heaUit deipmtmeut of the ootmiy where
eructed.
FwMGw-1, WeithCmuU-Depat—ofFnvnu=c tmmdN==IRewmoes—Divi mof'W=WRCSMUDCS RevisedAog}ut2013