GW1-2023-01680_Well Construction - GW1_20230214

1 1 r�rl MLL CONSMUCaON RECORD fGW 11 or ntarn Use OnIT. 1 will
I.Welt CONO2ebr en:6 It f"
14.WATERrem
Well Comer Name
",fJfJ J In;, f, tt
)!AC well, CAttinaeion rilnmbx "; Oum
rra C,o t is
Ltd]!Tame ft b clasett I V
2.WeB Comtnxdon Paiuit#: �N .� L FIle � G _
List all applikablrl► Ucox"IW tOnpermih(I.e.UIC,Cow1tp%fate.Variattcv,ewj IL R. to
3.Well Use(sheds:well use): IL tt. is
Water 8uplpty WeIl i
� NWi TO �. iwu�k. jS wis iz iAgricuwsl !1.
� ��ft Supply) adert wei Supq(clge) +u'ei�v t"s s �drA�r
ft.
IudttahisUCosmtzacial DReaidoutial Water Supply("Do l
rum A
N�-Water 8uppi<q Weil: fL l: 8. ' !
R ft. t6
gttffFx'12CCh^.rt�c
�kotaudmeter RcoaedinL[an ft. fL
Agaifer 8tcrage and Recovery Osetitttey Barrier 19.$ANtt3tGlto PACK � t '
aquifer Test [ Stonnwater Drainage it t< -- r
1 Technology []&Oddmm Coutrol ft. f
doottteat el(Closed Loop) OTtaoer 20, i<reste t1
l3eottmmW Retum Other n under#21 Rwwb
a.Date wdt(a)Cnrapietcds l� -22 well m# 0 0 ft q�1
Sa. +WellLocv Aoa: 'I' ir. /r-10
A 10V ���S fL It
g 3 P�Nam 5� S Facility (if applicable) ft. IL
it, fL
P6pnti Alidteu,City.and Zip R A.
.L h V a1.
CM* — Peal ItfaN6cstion No.(PN) —
5b.La*wk and leagWide is deVveshnintealmonds or dedmd degrees:
{ �'0°0 aufl4ei°at) 21 Calfaation:
&h(am)the wewsz rercaanmt or nTempa Sigtaime Few—d we Corat.aor DW
Bs's4 ft rhra forsb I isnbj,cal*that the well(+)»we{nett)c lmon ied is acconlaw
7.b this a t epafr to an axbtlag NeD: OYm or o Wh 111 NCAC 0aC.0100 or 11A WCAC 112C.0a00 iPeA Co11tlftdi 7 Slweelenb and dW a
lfirrrt is a rrpad;J atv6evx+r»�wsaArlcBalt Ly6nteallon and/xphzfn the rranrre q(the copy Rfrab mvrd has bras prowled ea the u{il miner.
repair imo6r 01 rmarks rcora r or ran t1x b=l-of tkfa fpna
23.Site diagram or sdditiattd well dstaMv
&Far GesprsbaMn or Aced-Loop Goal Wells having the same You way use the back of this page to provide addidoutl well site dewb or well
only 1 OW-1 is needed. hidicate TOTAL NUMBER of wells Conshuctim 4DWI. You may also attach addida w pages if necessary,
dtY7led;
� sUSMrrrA�. cnoxs
9.Total wdl d
lb 1W4epth
Abelow,band surface: 24t. For pry Submit this firm within 30 d*%of completion of wr11
For ntrkrpk welter tier All ew,!J'd r(axaatpre-3@200'and 2®1oaj constrnetiout to the following:
10.statle era lave!betaw top of casing: (R.) Dlvtston of Water Resources,Idora ilm Promag U�
�fxatrr!reel is ab ab ove mebl�,we°+' 1617 Map&erviee Centtx,Rale4git,TIC 27699-1617
11.Boreiote dt meter: ,_.(In.) Ub.For Ialet#{on way In add#inn m sending the foam to the Wmu in 24a
A r Y'I, above, also submit ow copy of this farm within 30 days of completion of welt
Le.12.wen ae y,onti oa method- �_.., corimcdou to the tbllowhig:
(1a+�,�'Y,�,dhoot pwh,eon)
FOR WATER SUPPLY WELLS ONLY: Dtvtdea of Water Remarces,Uwdavmad tn}e*a Coatrel Program,
`,�l 1636 Matt Service Center,Raidgk W 27699-16M
m Yldd(OW /y Method of test: I 24c.For Water Sutroiv&InllStka % In addition to sending the fbim to
r the uWasa(re) above, also submit c>Iste om of this fotm within 30 days of
13i1 Ca67j9WOA of wall construction to the county health dexrt cent of;he couty
whore Mumma