GW1--03290_Well Construction - GW1_20230511

WELL CONSTRUCTION RECORD(GyU-I)
1.Well Cont_s�ctor Wormation:
T 6RO31 70 AE$Ct�TtO?l
W41 contractor A'amc --- —
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NCn�WCHCC*Wraccmr/CmifimticmNvmbery// nth 1`1S OurmigA5 E tnri¢tnttic�scd�tlls ORIdAtEt�tfa 'iimbls
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Company Name 1 //�/� /JQ _
W l�l/ 1� l7 ::96r?ryul'ERCAS)SiGOFtTi7MAN M___aF d '
2,Well ConstructionForadt __ l�taas ro _ AL1AtErFX_—. TttrC6YE55 tATERtAI
List all t±ppllcp:+ls xrA constmeff rponmIs(ie.Wr-Cc myg_r Stt�F°arnarxg eta) -� - - - it'
3,Well Use(cbecl,well arse): b' IL
Water Supply Well: -- 17'SClLEEIY
FROM wo - DrAmErFR sLOrsrm. - 7mL7 im _IATFRmL
`Agticullurai ILhtnicipaUi'ttb7ic - it M is -
-_Geothermal(Haab ng(Cooling Supply) [aResidenfial WaterSupph'(single) - IL Ma>ti -—
IndustriallConu axial EIResidgatial Water Supply(shared) :-1&'i u0il7r -
Irri on r7t011 TO — MATERtat - E1iPlAC �Eh7A[EfHOD&A110y1T
Non,%ter Supply NVe11; — — - t /j�/1 i' �1�✓fi
'"Monitming �Recoven tl tt,
tk R
Aquifer Recharge lGroundmmer Rernediation _
- `.14_S�r�13UCsRltYEI:YACK Fa 61e`'. .
Aquifer Storage and Recovery r3Salinily Battier FROM To I nsaTFxtati_.. - eatPLACemmr ncmm
AquiferTcst [3Sto mwaterDrainaga rL IL
E tpztimentai'I echnologv SubsIdc Co=oI - >z -
Gwillelmal(Closed Loop) E3Tracer 2a°I?x1[L3�ircXAO attac8aaa,tsaml bsvis IFri>za�n .
FROM -TO --_. _ DESCRIP.CtOti aalor Inrduesi selYroc{:tt raze.etc.---
Geothermal(1-Ieating(CooUK&Ama) "Other fain under r21 Remarks) - -
d.Date%Vell(s)Completed: JZ Deli IDS
5a.1.'i'ell Location-, � LOkAM
c0�'�'I �� ��7 /s �5 ft 0 IL
FxcilitylorvgerNatitS Fncdity li�(ifapF7'_�-ic) � �' i;^'f"�a,'•N; : ��•,..s '
�a a yA�n AGEU •..
Physical Ad&=,City,aud Zip my t 2023
era tin;
.
S aunty r-d=l Idcati6casioII_l*o-(PLC' — 1 r�r:
6IF.LatitudF'and longitude inn de8reeslattitttat�/scconds or dcsatdtaldcgrees:
(iflvcll field;one lottloll$is suffiicicnt) 22.Cet1i_ficatiop:
f ZS Z 7 W
6,1s(am)the'aell(s) A'm anent or OTerrt�po?ar�' SiS��fe ofC a e11 Contractor Date
By sigm#t`e this farm.I hereby ccrt fy that the n ell(s)ties(Isere)canslntcled in accoremlcc
7.Is this a repallr t0 AR existing 1Y4I1: Dyes or No with MNCsIC 020,0100 or I fie MAC 02C.0200 Won Comtrnctios Srmtdards and that a
Ijthts is a repair fill ortt h7ton71 well comimcdon itrforatetion once explain the naaire ofthc spy ofthis record has been provided to the cell oftener.
repair under721 remarkssection or on the lack ofthisform. 23,Site&Wm or additional well details:
8,1 or Gcoprobe/l)1'7 or Closed-Loop Geolhcrrtt4tl Wells having the same You may use the back of this paw to provide additional%wll site details or well
construction;only 1 GW 1 is needed, Indicate TOTAL i`lU MER of��ells eonshuction details, You may also attach additional pages ifineFessary.
drilled: _ SUBAHTTAL INSTR.U01ONS
9,Told well depth below land surface: M) 24a, For All Wells: Submit this farm within 30 days of completion of Sall
Fornraitiplc seRs list all depths tfdlffere#tt(nwmp1a43 F o00'trad?@VM conmrtion to the follov-ing:
10.Static water level below top of casing: `7 a T-) Milslon of ti'Vatcr Resources,Wonl ation Processing unit,
JJ'vater level is above caring.rue'+" 16171VInil Service Center,RaleW LAC 276991 17
11.Borehole diatrteter: to �e _ (in-) 2 k For Iniection Wells: In addition to sending the form to the address in 24a
above,also aubnlit one copy of this form xvi4i' 30 days of completion of ti�eil
12,Well construction method: construction to the foilotving:
(k.auge,rotary,cable,dimctp-b,etc.)
T3i%ision of Wates•Resources,Underground injection Control ProortrD;
kla W.�.T SUPPLY lvEI.1,S QNL�': 1636?6bn Sen'ice CeWer,l?aleigh,NC 276991636
3 ,VAdd Grp) g Meemd of test=_— -- __--_-- 24c for SSrater Stitnnir&IniectionWelis: Iu addition to sending the form to
6te ,,s(es)abgve also submit one copy of this form within 30 days of
13b,Dis9stfcstaion ���/t/ AsuuwRc Z Z completion of well conskuehou to the county health department of the county
type:���Uul_ --__ - - - -
__.-- -- attzre ronstrtrctsd.