GW1--04190_Well Construction - GW1_20230706

1.w l conaaero ruformau /`��� L_C I
•
WetlCmtraMorName •• mom TO DISCRW11O1
• / - A �(, ,k ft. ),)sit iG�
NC Well CoaMaf Cettf5cetfon Number ._, A F
1� ) Il I" �11 �t `n7��.0U:?EtC�SL�rG:{fdlt'mi;Ttit�st�:ivelfiLL'Ot€I;1RE1Y�tR'' fi2aAteli.-.:,:•a�'�' ,::.
Cairo 1 De,l( agcl flu Seruifa a Fa"
J)1
DIAMETER fTmcxNrssJMATERIAL .
�� �� G :1dIIVNERCASIIII(i OliTFJGiNG!rReoth�rtutldwEd t$cp)u:� r, ::,R. k -=
1 Well Construction Permitd: d FROM z0 DIAMETER 1 ltCIQ1ESg MATERIAL'
L/trall applicable:tell eannnrerianRennin 0.e.UIC,Campy.State,Varimice,eat)- fL rt. M.
3.Well Use(cheek well use): rt. tr, tn.
WaterStipptylVen: :•12:&t?REF.hI:� >'-�- __ _. _ �.1'�- 4;'__---
FROM To ' imamSLOTS=Z1 •T tCRNESS MATERIAL ~`
Agricultural . nM9icipaltPublic 0 tr• R in.
Geothermal(Rearing/Cooling Supply) idential Water Supply(single) a, tr. In. -
Industrial/Commercial DResalentlal Water Supply(shared)
_Irrigation 'lgcogouTi '= :, ,W:+:� .i;=.:s_.;;=: rz ::. .;,
tr3mAI TO MATERIAL , PMPLACFMENr METHOD&AMouNr
iVoa.Water Supply Well (2 n. m �.)' i rUt' `'-�w ivr�L till,Montmring oRecovety - it R 1 N �
7glccuoa Well: .
• - Aquifer Recharge [(GroundwaterRemediation ft. ft. .
Aquifer$teragesadRecovery QSalinityBeaier 10i.SAVD/GILIMEEPACKIMEaieNtibtb):+• �.=: -:a;::'` .w.NT W:2: .
• FROat TO MATERIAL m smarrike Mrrxon
_Aquifer Test . t}Stormw Ater Drainage R• tr.
Experimental Technology OSubsideneeControl t R.
Geothermal(Closed Loop)... ['Tracer S 10:T1 GlO riifaeli eudltiauei:alieetr-'if�ietiiiii)*r_'•_ tg&,,=' u
_Geothermal(Renfinp�CoolingRenun) fOther(ea laiauaderF21Remarks) °t TO DfSCR�FfOY(color,tutdnev,rotYmckf�pyxratritce,elc}
4.Hate Well(s)Completed: °��'�� Well Mg IL /G G n f�-: cl� .
Sa.Well Location: /31 h C/.n 4' f.� -e
p 4,142C Q�A�. / ft. fL
FaclitylOwner11 Facility tog(ifippticebin) R IL
r) Oo3 t-eAetif f- /I i - fr. ft. ("a ;:,;^ - .,
Physical Annul,city,gad Tip tti a �r 4$
2011E\id!#lr8
Count, ParcelIdee1i6ectioa o.(PIN) ; l tJ�
Sb.Latitude and longitude hi degrees/minutes/seconds or decimal degrees: Ini�'+�,;, '' -.rr ht,k
(i1watld W.oaaletAangiaso�icimt) 22.Certification: ,6 �f . - `::vi =;�.4.a
• ,�� .�C.. � N �f �O G sy, W
bet Adg,, 6-._ ) y .2 ._
6.Is(are)the weli(s)1Permenent or [Temporary SignatureotecmnedWellceanacror Data
��`o By NBring EA Joins t hereby sera b than the wells)was(here)caurnresed N accordance
7.Is Ibis a repair to'an existing well: ❑Yes or with 111 NCtC 02C.0100 or 15A NCtC 02C.0200 Nil Co utntaton Steadorde and that a
if this Is a repair,fill out Amara w crion bfareiation sad again the Balmy QJdre copy of this'mod hot beet,powder!to thi util owner.
maim-War learn or on the had ofrhtsfoaar.
23.Site diagram or additional well details:
You may use the back of this page to provide additiened well Site details or well
8.For Geoprobe(DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW 1 is needed.Indicate TOTAL.NUMBER of wells construction details.You may also attach additional pages if necessary.
drilled:
(�� INIMITTAL 1NSTRf1Cr1•QN -
9.Total well depth below land surface: l (h) 24a. For All Wells; Submit this form within 30 days of completion of well
Far mulapkwe14 Avail Awry bedfjeren:(eaample.30)200•alai 2,14ID0) ca»stnrctionto the(alloying
10.Static water level below top leasing: r _ (IL) Division of Water Resources,Information Processing Unit;
1Jwarerletel tr abowcathe we +" / 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 ' (In.)
t / Vb.For IRleciton Wetly; in addition to Sending the fionnw the address in 24a
12.Well construction method: i O`( t•Y'l ( above,also submit one copy of this form within 30 days of completion of well
(ix.auger,rotary.table,direct push.do.) v'' construction to the following:
-
FOR WATER SUPPLY WELLS ONLYr Division of Wafer Resources,Undeitground Injection Control Program.
• 1636 Mail Service Center,Raleigh,NC 27699.1636
,t
13a.Yield(gpm) Method of test: Irk.For Wafer Sunuly&Infection Wells: In addition to sending the form to
• 13b.Dishtfecdon type: 11 (/ v s/S address(es)above, also submit one copy of this form within 30 days of
Amount:, C- / completion of well construction to the totally health department of the county
where constructed.
formGW-1 North Candi=Depadmeat ofEavi,omnenml Q,>aliry-Divfsionof Weer Rwaatta Revised 2-22 2016-