GW1--07149_Well Construction - GW1_20231101

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WELL CONSTRUCTION RECORD(GW--1) !''Par mild uaCUS Only, — —
1,Well Contractor Lnfo nretinal
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WeliConoacter Mani Nftorit TO • D�CRfP/7[k�(, _ _ _ •
R. F.
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NC'Well Connector CattificmuonN-ten§sr
7tAlT1tFitcaSt+t�.(fo rmutetstawIA(tf 1
Morgan Weli,&Pump,l lC t __ t TRrcx,Mss MATERIAL
-- - --- - . .------__— a ft, ft. 6 U9 ru sen2i PVC f
Coropaayliame
�y�t��f7 O,{3 1 il6iu ` is tTUBI+iGrt ; r a3
2,Weli(atm5tr9t tlat!Ptx�tit#: 8I r'ti'�J " 0 Boasa MialtTEfs Tteres tanxi,ts
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Mal ttt:pik*nettIconrrrr atiae pan*,(ire;tie,t5onti, ear Its i__p 3,Well Use(cheek well use)! fr, ft, rE<
1Yater$ullplyWeilt ram _ TO__ ntATt 5L(yr�7�G 7tttctst+ss ,un Rtht
0.A risullturd DAds�icipa lic ft, ft, in.
EPDXIIP.112141 Meeting/Cooling Supply) IRIAesidsttval Water Supply(single) h. ---- t, l6=
DIadesnia1Conimeinl DR€sidetttial water 5 y( ) >j+9, l> ; s,,, :-• : ..;
Itri�ation MAi---- Va au EMU. _ impLAcFExratFtlxpn&�>t coulee
4 ft. 20 rt. !swot, modl+iart littleruti�r 1Yc11: "
JMo itosiog -- rift Y
ltte _tt Val4 ft ft
DAgnifor its riOSamd,,wtater Re:mediatiotr
Ohlulfes Stomp and Recovery riSalinity Waxier --- TO mutual. R,rrxcacEM METHOD
EAquifesTeat . OStorrewaterDrainage ft, ft.
®experimental Technology D$ §id«tct;Cantle' ft, fa
CI Ueodterroet(Closed Loop) Tracer :10,DR!Lm_ atOG:r( l+adui a 'tCa *y .. , -:4 s..�:_'
MomMom To�r� - U SOOPTIrltitc21.w sslflrecktvpt.Malastx.eu.1
l thermai fil atino/Coolulg Ream) f O bet(explain gttder•#21 Remarks), ft, • pit, it_c d d•
4,nate Weil(!)Completed:4``L.7 Well Z>7ra H' r3 6-1N/1 :nl!/9-•
�2.Well tt9A: +J ry c i h V .//L toc `�_..._..-- -"-
faellitylOwner New FasdKyID (iftepplicable) _ —. -- -- - - -
751
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PhpsteetAddt€ss,City,airdZip
L,Jztln _ L
County Perm!ldcntiftsationNo.(P _- - -- ---.--
3b,Windt and longitude in degrees tminutes/see0odt or decimal d gnus€
(ifwoli field,one Woes is aufieient) W,,u __ ea
_� 2�,t:;�tiCucatlatt �
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6,ls(ase)the wuu(s)EiPermausnt or [ Tempos_r Sigiaw,tsof S 4W tI ontmtor Pate
By siviny title fare,I hereby Berta that the.RV)mze Opel sneslrttstsd in aeEnrdnncn
7,Is this 0 repair to an existing well; JJYcs or EiPio with I5f tyt',tC(?.C.010Aor At Commis/tam soon ton&rod that a
tf lh,+s it repairs/HI oat,6ioeea trell canttractiontnfonoatkn and whin the moors of the AtPYofthis rseon am bte wpravfr d toths xwlf CiWgerr
repair PILAW el ixairrris?dtina peon the hack eflhls form 23,Site diagram or additional well details;
8,For +probefDPT or Closed-Loop Gentbset l Wells having the You may ttse t bock of this pugs to provide additional well site Malls or well
con on,only 1 OW-I is needed. indicate TOTAL NUMB)a R of wells construction details.You may also attach additional pages if necessary,
dultod;t SIUBMITTAL INSTRUCTIONS
9,Total wet dspthbciawlandsurfgset, ... C.- -- -- ._(t) 24a,For At Wells! Submit this fort within 30 days of completion of well
- Far r>mairiple wile Walt depths If&lewdresemple- C200`endAV lion to thefolkweing:
10,Staticwafer level below top of rg ing: 0 _ (fr) Division of Water Remoras,Lifor nation Processing Unit, .
Pater level ie above castug,um"d•" 16171Mall Service Center,Raleigh,NC 27699.1617
11,Roreltcte diameter:6 1l8 00 24b.For Infection Wells: In addition to sending cite form to the addtz_;s in 24a
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rotary above,also submit one copy of this fined within 30 days of completion of well
12,WellrotlstrustionrnsLhod: �_ ._�__-- __ •-.---___. eonswetionto the following:
PA eager,torn,cable,dircetptab,cte.) '
Pivl,4o1;of Water 13e:mu-net,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY; 1636 Mail Service Ocntsr;Raleigh,NC 27699-1636
13a Yield(gpm) 1 60 . Method din*€11. _ - - 24c,For water Simply sr infection Wets; fit addition to sending the Rem to
fltaturetedci<orfoa the 4dtetss(es) above,also submit onelcopy of this form within 30 days of
t$h,Disatfedon type.; _ Ainouxt: -' completion of well construstlan to the downy health depat utent of the county
where constructed.
F SW-i Noali Coronae Annulment of ffinnvereentel Quality"Division of Wet€rResoursss Reviled l 72-2016 •
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