GW1-2021-07950_Well Construction - GW1_20210809

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w*JA-C- STRU ON RECORD IW lea®l Use ONLY:
Ibis tamembetisod far�te or®Ilipleadk
1.Well Contractor Infosmw&n:
1FHOM?lam TO IDffiCB<<h70N
Well tName a a. it' 3,) R
R sv R li
NC WellC Ca Number WO T[6RCASMG firmo>aenisedw�s OR'iEtEB
FROM To oL [ Mw1EWAL
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6;�Namo 16.'UOIIMCAS4'IGORTtlinM .. )
FROM to nuM�11 tIMTTflttA1.
2.Well ConshneiionPermit#. f'� R .Lf'7 ft. in
LisraQappliaab/e urApermits(ia Camery.S Parz�eoG/r�[dioq era;) ��R g R
3 well Use(cl�ecltwe8 asek 17.SCRESN
WaterSttppllyWeiN FROM ToIOAgricUltnd
DleMslme SUO[Sf� tH[� MATffiWL
aMmit ipaVPublic R �y DGeofamal(H oling&VP r) ORe!sidentW WaterSupply(shVc) R 4L
p1ndhdCommeceiat Jaidetdial weber Supply(shared) Ia.GROUP
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lvun-water i�lv well:
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Ommitoring OReovay
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Rejection Wei nslomer
p aGroundwaterRcaodiation 19 SANDIGRAVSLPACK 6
FROM TO MAT BX% HIMI/K�R1rrME1HOD
aAquifer Sturege an covert' O.Wfi ity Barrier R R l /
OAyuiferTest aStarmwaterDrai- e
aEmmimseta)TechadoW OSubsidww Cadet 2L DRUAZ4G LOG a>txh a
aunt(Closed Loop) aTraca rao11 To urn
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aGsOhamal(li Rdum) 130ther(explaintmder42lRetnvks) R R19
R 6 R
4.Date WeRS)Compleftft Z,VWell IDO a R R
sa Well Locatioa: 3 a s s�y n t,J-7
IOwnerNum Asc ty0SCdappliwWe) R ft.
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iZi S FlA-t�l fit•--(..Aak�.3 �s t� ft. R
Ph=:dAddress.City.Ind Zip n r% fi�1
Cry t'meelldNa(Pnt) r}�\���L1�1 CE�I•
5b.lAfttade m d LoRIeftde in degreesh®nutedsecen&or daimal degrees: 21
(ifwdl field.am h0oagissu&eiau) o�
,35c' i3` t-4" N `7-1 31'3:2 ` W Tj��4
SigaataeofCaurwd WenComnssor
6.is(are)the we»(a):_Qr D ,c or OTempotary By sigme dkff fo a./may cav y rbw de w2(s)"r(Bw4 cansouaed m accordance
widr 15AHOW 02C-0100 or 15A Ar AC 02C-0200 Peg CaarnocOmSrandasds and flada
7.Is thb a repair 6n aD exis6ag welk ElYes or cW ofdds nacm dhm bearpromW m dxuell owner-
1f parr pia rr*21 re l o secs a ell aommruaran mformanron and a pdah+dx,mrme oldx 23`Sloe dmtgnm or add well
repsirmder'2/rene�Lssamonorandxbmetofddsfmm
You any use the back of this page to provide additiotnl well site detente or well
L Number of wells contracted: eonstrurxion detatt You may aim attach addilicinol poa s if ncrossary.
For moltiYplehyrcdmorrwnwatersappEpweEsOAZYW&AtsaemraomDareelaar.You Ow SUBMr1TALIltMCTIONS
sabadrooeforar.
9.Total well depth below land surface: T (R) 24a.For All Welln Submit this form within 30 days of completion of well
foraadttpleurOs/maddytihr (�plo-3®200'md2®1003 : conshudiontuthafaflowinX
10 Static water level below top of (R) Division of Water Resomeet.Infarmatior. U8%
if—level Is above cmft use'+- 1617 Mai!Setvae Center,Rdegb NC 27OW-1617
11.Borehole diameter. [ro.) 24b.j•or Inieelion Welk ONLY: In addition to sending the form to the address in
24aabove,also submit a copy of this farm within 30 days of completion of well
12.Weft coust uedon mod M/J�a eous6udion to the fo(towing:
(ie'agar eclat',c"`'duxcpmh ate) Divi*m of Water Ramurces,Undergroasd Injection CoWRW Psegraro,
FOR WATER SUPPLY WELLS ONLY 1636 Mao Service Center,i Rsleq 14NC 27694-106
13a.Yield(gpm) 40, Method of test: je tee► 24c For Water S�nis&Laiet tioa welts:
Also mdonit one copy of this form within 30 daysofcompletionof
13b.D t� AMMO {sue-- well construc
acted-4on t4 the ommty heahh department of the rowdy where
conshl
Form GW-I NmdiCarolin Depwou atofEnsimommt and Namara!Resomaes—Division of Wanw Resmaces Revised Auma 2013
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