GW1-2023-01753_Well Construction - GW1_20230223

! I solo Vr
WELL CONSTRUMON MCQRD MR-1 For Tnterna!Use Only:
1.Well Cflntraeter Information:
�arnr.iS ,bS cn tLWATMMM
WcltConuactorHama FROM TG t)EgL`glMON
1f 6C Pr o rt. ��' Ncllo�
MC11FellCavlractarCeitificadanNumber 6ID o & <<C),-�
s OVMR r AsnvGt8,rmutd-C&ed welts)QBLIMNIM[r j
Pr U--Q S'.Q_I2_t.l cc S � h C > most TO otitht� cart i nta�luar.
r ft. ft. p
CampanyName �•
zG.7lNPt�ItCAsiNG48TFiBIIVGf FctotiQdlan )
2.Well C.onslradan Permit Le rllaal TO nrnl� xiRcttlaess
List ult applicable aril causimcdon permits(te.UIIC.Caluuy.State,Variance,etc.) d 36 R' 6.2S' 'u• ,S 4-ek,
3.Well Use(ebecli well use): rt. tt in.
Water 94ply Well: zz.ses
i•8o\f TO IIFAbrBTLIn SLO'1 StZt< 7.'SLCSNESS Rt1lTERIAL gticultttral �Swlonf paUPubtic tT. ft, In.
Geothermal(lieafing/Cooling Supply) tdeuttal Water Supply MgIe) M
dustrLA/Commereial DReacatial Water Supply(sbaied) ittGRt)UT
IiTI AtIOR EROM To- htA EiIPI ACL fEtiT14iIIKOB&+111IDGh7f
Non-Water Sup*Wolf 1- 2b R- 1 I
Monitoring itcxovery
[I. AquiforTest
fferRecharge DaroundwaterRemedimioniferStoingeaudRecovery Salim gerimcntalecltnoto� �Stl6sidcnccColtltol ft. it.
2iI:DRU.1,II�IGL4Gtherrital fHcatiti lCoolin Rctufnj (}ther(e tainuader#2tRetitarlss) °ER d Ta I)PSO ti r ON.,oror traanea.�nlm� .apt
6 f. . C;la �lierb.u�r
4.Date Wellcs)Complekd: 2�well mm 23 a ft S&r (t• rah 1•�
Sa.Welt Location: �• tt.
CncllityldwuerName FacTryli7pttfapplicable) ft fL I `v.am, e I_e„G V
9LI53 S1%e)r'Few Vi Gw Tt: . FEB 2 2023
Physical AddreuXity,ond2'ip
v>o�
C4unlY P&Zel Idenht'icatiortNa.(PItr`j
Sb.Latltadeand longitude in degreesiminutestseconds ordedinal degrees:
(tf%vell Held,one Iadlong Is sufficient)
Certification:
3S° 44iS. 3olc.�zt."xg��s�' �.� 2Szay 'r W
6.Is(are)thewell(s)eP-manent or E3Tempmm7 gaatutea€Cottifiedti ctiComwor Date
By sighing liar fam.F be-by wdfy that the u,&(s)nos ftrere)canumeted in accordance
7.Is this a repair to an edsting wells OYw or uuh 15ANCAC 02C A1a0 or 15A vCAC 02C.0200%il Conslructioa StandvrdsQnd that a lrlhlr it a repair fill not L•161M,.-ett eanUrauton tafs+m+ar?orz and e�rtaia dre rmrnrrofrha ropy ofdtirxecordhas been provided ra the .»tmu a, er_
repair under021 remurkssectiartor on.the bark afrhWbFm. 23.
S � 1,
adram or additidnnE�detatlsa
9-FortaenprahelbPT or L'losed�oog @;'eatfiermeF WeBe Bnviag the soma You.may use the week oP tfiks pugs to pcanide eddidanai wen sacs dcudis or wwi
conatcuetion,only I OW-1baut lvd.IndicumTOTAE.1!'EMUMRortvelis ananmeacmdetmm.you snizyalsaatmehaddatianalpagaeifaeaasaary.
drilled:
Ci3[tlVi1'i'7'3i.71U4Tdtt'SC'I7[lt1lc
4.�otat well depth below lands[a#'ace: �J O5 I'
For multiple uetlskstuit depths lfdr7)erent(emmpL-3@209'mrd2e@16D) (ft) 2Ag•EQr!#Il Weller SllbMII this form within 30 days of completion of well
sonstruetion tothe following:
iftrater level is aware rvsing,are
10.Static water level helow fog of eating: �� fit.) 1xvislon of Wat�rlitesourcws Morma6nn processing Unit,
"+� 2617 Adel!S'ervice Center,RaleipL,NC 276991617
11.BOr2holedlameter: �. ?S: (ia.) 24b.Far Ittiection Wells., lb addition to sending the iami to the addtrss in 24a
lx.Well const=ticDon method: A Q tru► abgvr,,OLD submit.ono Copy'vf[his form N1lhlll 30 days of Completion of well
tie.anger.mtury>cabIc,dtneetpush,ue) constmedon totbe foltMns,l
Tait WALTER SUPPLY'kVFM ONM. DlvWunOf Water$es urces,Underground Iitjecgon Control Prsgramn'
106tflallSiMmCenler,Ralop NC2709I636
139.Yield(gpm) 5 Method attest: ga 1 Carla iW Mr.$DF Water SwnI-A�II i§940 M lc; In addition to sending the farm to
1 _ ilie adlin s tes) above,also 'submit one co of this form within 30 days of
t3b.Ilisinfecfion type:C'�h 12 f;rIA i Amount; S �5 _-__--_ COmpletial2 Of well rimstnirtinn tr.th..,a.,, t..,..t.0 1--_,-.- . - .