GW1-2021-03207_Well Construction - GW1_20210625

VT CON ' err itnw lltl�['U�tD(f W-11 Far Istoetnat vac Only:
1.Wan C.ontraeter Idormattiow
LL1.�SSC7 � TO u�
Well Canuact r Name IL I
NC Well Convector ceyttfication Number
r. Gtl
Gay Name 11t OlR 1 TO DtA?
p� t1�Q7 i A MAT1lRlAM.
r� 1 D7K •' 'rffiCKtt688
2.we Coutruction Perstdt tf: d� c�� - — it. !in;
Litt all WpGoabls well coru`arclfoA panoritt ae.Vic,Comw Smut.Vartanoe.etc.)
406
3.Well Use(Check well use):
Water S Wan: Fs0>tr TOni�xcerste rota Size Tmcttrls MA7ii4Ltt
A4ricuttural DMtnicipal/Public n tt.
Geothermal(Heating/Cwbng Supply) ,aResidgetial Water Supply(Single) IL
bAWtrisVC,OW=erCW DReside:ntisl Water Supply(shared) i
M TO MR tBAiAt Qr.tC�hffiD MYTHQD AhitIHJNr
et. tt i
tWa-Water gap*�4'ell:
ft. ft.
Aquifer a �Groundwatea ttemudiation trll2a t!AClC
Aquifer Storage and Recovery C)SaiWty Barrier FROM TO M AT�t tt �trt.�Cct+slz�r n...... to
Test 13Stormw&W Drainage
E:tpwkacnW Technology DSubsidenx Control It.
(Cloned Loop) 13Tracer
Goothee�1 cells Return Other lain ttncteu 021 Rematics nRt>St m Te>rt oaks wiihoei� see
n
4.Date Well(s)Compleled:6�L. Wen M0 ft. !LL
Sa.Walt Locadoa:
roan- td 993:1n.
Facility/t)wmr N4mr J�Facility IN(if opplicabia) R R.
"iesl Addrm.Citys ad zip tti n ►rs£iCrt1�•' n
//V
county Pared 1tlenti8cation No.(PWy
Sb.Ladhkde and longitude in degrees/tttluntes/soconds or dedn al degrees:
(if well field,one is suffiaieat) 22.
n Cetilflcatlon;
6.IX AM)the wdl(e} Per"neat. or DTemporary 5agcaahas�e of CmKi&eel 9vcU Coaaactar p
4 tirft rhifi m.I her sby ratify that the well(*)was(awv)c»natrvcted is arras dance
7.Is this a repair to an esWiag welt: (3Yes or DNo with 13A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards Sad that a
.[("&iota 1a a AWA(r JW OW hw"WM Caraatrnetfon i*ratoriwa =;uIatn the nawv ofthe ropy ofd w--d has bees provided to the nail owner.
n*u&wrd-#21 mwarkr section or on else back of thin faun.
23.Site diagram or adtlid"M well Pik.
8.For Geoprobe/DPT or Closed-Loop Geoibermsi Wells ha-mg the same You may use the back of this page to tmtvide additional well site details or well
comstrucdcn, I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additionrd pages if necessary.
9.Tote!well depth below land sarface: - -gy-
For ( ) 24a. Forte: Submit this form within 30 de apttthste uWk Nat all depshs rd ffmw(esan*-3@200'Sad 2®100'} days of completion of Well
construction to the following:
10-Sgt*water Wei below to of a°�' I
Ifuct �& bow c,,�tar..p.. _ (�) Division of Water Resources,Information Processing Unk,
1617 Mail Service Center,Raleigh,NC 276".1617
I I.Dortelssle dish:—"—(11 )
a f 24b.For Ealgaha wgh; In additiOn to sending the farts to the address in 24a
12.Won oomarrwetlon method: ( ,��)l above,also submit one copy of thisfcrzm within 30 daysof c
OW.rainy.sable.dbm trust,etc.) �� construction LO the fallowing: otnpletion of well
FOR WATER SUPPLY WELLS ONLY: Divislon of Water Rcmuroes,U ndwgronnd Injection Control program,
1636 Molt Service Center,Ralei91,NC 276"4636
13a>.Ykld(gpast) Method of test:= i/jam 24c.For Water Sunnly ,idie94O VIA:f In addition to sending the forth to
13b.Dhiat edoa the (es) above, also submit brie COPY of this farm within ?0 days of
type: Amount:_-__1 �'�amnPtetion of wadi construction to 16 county heatlh department of the county
where constructed.
Form ow-1 Nato Carolina Deparm-st-f&,,ri onu votat Quality-Division of Water Rerasunoea Revised 2_22_201 ti