GW1-2022-03430_Well Construction - GW1_20220318

For Intmal Use Ty
1.Well Contractor Information:
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IVoll Cortfraoior Nn,ao .5 � Q
21114,
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NC Well Cet>arrWOo CortiAcrttli n Nurnher
Cenhidy,Brothers Well Ming, Inc. ® � 1� L)
Company Namc 7 Z
3 Won Conslnieflon Pentdt Ot ,/W L 00 bIAL
List all applivable troll eanrrnrrrtoriiwrm rr Jl.e,111C,Conno,,Utw,i'arlanee,etal In,
3.Well Use(chock wall ttse)r
10oothem-1
u Went 166
ultuml Munro L;141io It. .n. » In, d /Z D t7Ci
ormal(MoatinglCooling Supply) bntial Vvator8upply(s{n�lo) A. n. In.
tiallCommemial DRooldentlai Water Supply(shared)
ttPROM TO
ater Supply L41: n. D h• a a�e
WA
on o : -- ---
a rt
Par Rcchatge Cirotndwatos Rcmedlotion
fer Stomp and Rwovory 98lialty Aarri®f ENO
W Tait t)tolmwater Drainage a p IL �d M +n /b P
rimonia)Toahnoiogy 13subsidarteo Commt n. n.
emal(Closed Loop) frttcor
(aEfttoollm Rolum 0 in undor N Ram
n. � a.
4.Date Wells)Completed, F „a Vail IN j 5 t, b 4.
So.Well,, ,,
Locallont.�/ 7) m. n.
, 1/ 1/a' n.
Faellity/Owner Name --� r FaalliryiDa(i(appttaablol R' & R•
.3 o�wri YU C
PhysicalAddicu,thy,and yip
County Mom• PwWMaraillestion No.(PIN)
5b.Latitudo and longitude in degrvWminutea/seroods or dedtnal degtnM, + 1 It 4a
(If wall field,one ist/long is suiilelont) CO-:
r W c!"`?'' t t�`
N Lkc v2��. �' �lSY1,a.�.cJ ,n?o F A Z
23,Sift diagram or additional wtll detaikt
a.►iKAM)the wen(R) neat or DTomporary naU+rr of 0MI11W a Corrector n�t�
lb,rtentag this f6rrn I Aendrp ca Ito,that tbo+++lift)MU own)oo w Meled in occof*nrr
7.Is this a repair loan oltltKin(;went �YC@ or a'ItA SA NCrtC,O?C.O1o0 orI3A NCAC 02C.O200 Well GbnrtrtrN,a+Srondat�dr anti that a
(f ahb Ir a rtpal r,JIJJ oat knot+n nr11 m+orttrruNton lr�b►mattoa cad�lahr tAe natrae nlrhe cowgJthlr rerarrl bus been pro+fdded tothe aril oarrer.
ropalr isoder Hra Il rrat*r rerttn+r er on the back gPthtr form,
N,For Caoprobe/DPT or Cioved•Loop Geolber mal Walt WnS the same You may too the back of this page to pmAdo additional wall silo details of well
construction,only 1 OW-1 is needed, indicate TOTAL NUMBER of welts con:ttuoion details. You may oleo auaofi additional page{f necessary.
drilled:
9,Total well depth balow land surface, �_t-�(� ....>i M 24& Submit this (brm within 30 days of completion of wail
Mw mrrhorlo uWk hit all deprka IM10mm(amaprre•302 M,' 1, r iOffl n,Mlon to t fie slowing:
10.Made water novel below top of cael"I � � (It) Olvielon of Water Rewt mv%Infora+ation Premtllttg Unit,
{/ntfrer letttt U share rarA @,arc"+" 1617 MAN Service Center,Raletg}h,NC 27699.1617
i I.Oorehok 8iamtatort� (in.) 24b.Far Lltsetlntt'", I in addition to haling that form to the address in 24a
Rotaryubovo,also submit on copy of this f brm within 30 days of completion of well
IL Well wait..Ctble, ettelPodt ...,. ,.�,e. cottatfuetion to the tbitowing:
(I.e.sager,rcaary,arblo,dlreel ptnh,eta.) I
Division of Water Rsrtour+ees,Vaderlimad injection Control Program.
FOR WATER SUPPLY
WELLS ONLY; 106 Alan Borvica Center.Raleigh,NC 27690.106
13a.Yield(Rpm)_.ram...... Moaned of test:...:,L_:...... He. in addition to N the farm to
the a� w{Or above, also subm t'm o copy of this fort whhin 30 days of
13b.DIAnlotlon typo, Amommi co"jelion of well oottstruction to,the county health depnrament of the county
where constructed.
Form dW1 North Cemlino Deparo wnl of Envfronnintal Quality•Dftlon of Water Resaufccn RcYtad 2.22-2016