GW1-2022-03480_Well Construction - GW1_20220323

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ILU M U - of n ertla se n y:
I.well Contractor,intarniationt
J0110 G. gannedy
Well Cantmolor Nomo � � � �
2126-A '
NC Wolf Coairsata Cortittoaiiaii Nnrnbar
Cannay Breathers Well D011ing, Inc. n, TelR.
CampanyNoma 3�4 Sid P-U
s.Wei►Cottetroetion Petnalt Nt W C a I-0000Z1+
Lil►aNappltmblo uvtf canrintedon prrnt Is il.a, aunOt taw,Varlante,eta) R.
3.Well Use(cheek well uae)t n.
a er NuMpty WeIll r
Agricultural R, r n. to. yy �i, rd pea
Qcathorntal(Healing/Cooling Supply) 191tosidentiel Water Supply(single) R, R, In.
tndustrial/Commtmciol E)Rroldotnial Water Supply(shared)
arN star Supply e1 t o n. fl R.
Manh n )terxtvt hG ft.
well:
Aquifer Realtargo �droundwnter Romcdimion rt.
Aqulhbr Storage and Recovery 0gaNnhy Barrier
Aqulrer cost C)Stortivrater DtofaNgc �� n• y R. `�{,�+ l b
13xparlmonlalTechnology [3SubaidaneaControl
Owthommnl(Closed loop) bTrow
Acatha al("callflarAotm Return) Mtn u or d oma s
O
4.Date Well(a)Completedt Well ilkN
5a,Wall Loendont n. n•
n. n.
Facilily/OwiwNatne PkililyIDN(Itarnlloable)
Lot 18 n, R. 'y �
n,
Pliy. al Addrrot,My.mid Lip n,
_Jam
Cuunty, �� Perot Idmtittosthm Ne.(FIN)
6b,LNNtudo and longitude in degreWminuteslseemads or deelnutl degrees:
tirwolf Hold,am tat/Ions fs eunkbm) U.Off"licattont
6.Is(are)me wetl(en rermaaettt or ()'i wperary tuituro a n o onuoctar ter
oy t It tAfi Jbrm,I hv*,cmito'drat dro Faits)"w f mv)eotumrclyd In accarinaro
7,In this A repair to an o'sisNflp wells [3Xea or allo u1th�1A NCAC 02C,Of 0o or ISA?CAC 01C.02000a11 Comm riton Standards and that a
Ifthls ISO/v)mfr,fill ant laroun+loll msintellmt Iiirem illon oftd mplato the narlov of the rapt'of this rmrd hat bets pmlded to►e uv)l w w.
roptrfr ardor f111 naainrtr,ecflnn ar on tho Nark tirlhlafornl, 3.1, {�dltt;ritm or additional well detalku
B,For Cooproboll)Vr or.Close&Loopp GeMbermtil well s brAlig*0 some You map user the book or this page to;provido additional wall site dotails or well
constriction,only I OW-1 Is ntudod, Indicate TOTAL NUMBI3111 of molls connniaion datolis. You may aim auaah additional pope Irneoessary,
drilled.
9.Total well nth bdoiv land aorbect y n•) RAN, t Submit this arm within 30 days of completion of well
Ror tnuhlpk units lut all depths Yd(pbroat fera*o �t7n0'nn iRlrl carutfrlot on to the Bowing:
10.Stage water loyal below top of"ling) ) 'S (R•) Oftlon of Water PAourvi*wnlprmatlon Puling Unit.
0110101'1011111 ahmv Castap,ltitr"+" 1617 MsN Servloo Center,Rakish,MC 17699•I617
i t.Boreholo diantateri S 3/`{ bier) 34h.JAtWMjWLVAt in addifloo to wWW the form to the address In 244
Rota!, above,also submit ono copy or this lbrm within 30 days or completion or wall
13.Wci1 ce nt.,11.,trt etkodt ,,,,„,„.,, ..,,. .. ..,.,...,..,,.�,,. Commotion to the fallowing:
(U.aup.totary.cable,41moi push,etc,)
931visba of Water Ratoarea,Uadergreiriad 1njeMion(7amtrol Program,
FOR WATER SUPPLX WELLSRo NC 276WI636
.•� QNLYi 1636 Mail(lewlco Confer, fish,
13a.Yield(gpm) Mothers of tttsf: �1 " 24c. t to addition to sending the form to
��� I the ciddrawKcsl above, also submit 'ono copy or this rams within 30 days of
13b.UlArtl etlon typo- Amami completion of well constriction to Iticr courtly health dopartment of the county
wttero constructed.
Fotm oW•I North Comlim Dopnnntont orEavhommntal()uallly•Division of water Rosouft oa ttovi.w!9.79.3016