GW1-2022-03767_Well Construction - GW1_20220404

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Wall
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NC Well Comrector Co,tineatioa thmAer
Cannedy Bmthers Well Cdiiin , inc.
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Congtstiy Nome { �j
2 Well Construction Perndt 6:�aL11.L f �� t
liar afi appirtable trntf rnrralnrctron permits t+.e,�Si� aunty ate,i'arlamr,etc.)
3.Well floe(cheek well use):
afarSupply Went 1-MAW
Agricultuml �M iiaVs'tibiic R. R. t• Is, a/2 yI rr• VO
Oeothtxmat(ltsetinglCooling Supply) tmi Water Supply(single) R.
R. Is,
IndustriatIcommerciel C)Reetdontial Water Supply(shared)
Imallon ON
Non-Water Supply c-lt: ID R• D R' o>�a..Q OW-
Monitors �1tet;OverY 1G n.
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Aquifer Recharge �()ratndvrster Remaliation
Aqulfbr Stomp and Itecovoty 139811nity Barrier
Aquifer Teat 138utlltttvnler Drainage D R. p R. t, TILAAea POO&—
Expodmunial Technology DSubsIdaaee Comml
Ocothertnal(Closed Loop) ®Tracer
QaW amtal(HomingCooliag Return MWr lain under 021 Rarttsties R. D R' /V/tas^r►
4.Date Well(s)Cot llmd: 3 O RI IDO 20 R' / R'
So.Well Lmdon: v R' son.
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FecililyiOwrMr Nato Fac it IDa if eppticsble) R. R.
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Physical Address.Chy.end Zip R• R'Cuunly Pawl fdentplation No.(PIN)
6b.i.atltnd0 and lattglttsdt+in degteas)tnlnutmrlseeottds or declntat degrees:
(if wall need,orrc IaMong Is suinatent) 2E.Certification: a r a s
. .3 �ell W
6.istare)me well(g)OPIr tanent or OTemporary oftktt contssgor rMc
By signing this famt,I hemby csrr(b+hot Ike irdifa)ww ft orm)co+utmcrrrd is orm*nce
7.is this a repair to an cldsting Nrellt [3Yes Ar +�11k i5A NCAC QiC.0100 or 154 NCAC 02C.0d00 Well Cons mvlerr Smadank and that a
(f ihls Ia a repair ill oat Amitu sill constatcrlon Inrora lion Mid a#aIn Ike native of the , off of this retard tart btsar p vwcd to►Ae UVIt awaer.
mpatr wader all romardr xaCrtoa or on the back grthisfornr.
23,Site ditrgt'arR or ttddltloAaf WQ1t details,
S.For Geoprobe)D1tT or Closcd•Loop Geolli mal We s lixving the some, You may use the back of this page to jimido additional uteli site details or well
construction,only I OW-1 is tte" Indicate TOTAL.NUMBER of vielis constrtuxion tktatle. You they aim attach additional pagoe If necessary.
driNed:
9.Total well depth tseltwr land surbco: 3 s%) 34a. Submit this (ben+ within 30 days of completion of well
F'or tnulj6*sills list oll daprks prd(Omm(example-T(r�i R•to irdr) construatton to the ottawing:
10.Stalk water level blow top of casing:_.,_.,, (n•) VIVIslttn 0f Water RMUrOM[RfOVMtW PrOMOn Unlit
(jtmter keel is adorn cosbtg,me"+" 1617 MAN SeMeo Center,Raldgh,NC 37699.1617
11.Bomhole diameter: __oto 24b.Par inirtefAn iN®ltat In d6dition to w Wbv the form to the addrim in 24a
�9t� above,sits submit one,copy or(his form within 30 days of completion of well
12.Well rnnstraetlon tn�A.; x oonatruction to the Ibltowing:
(Le.auger,rotary.Coble,41mel push,etc.)
Division of Wow Pt Wrap tludergrannd Ittlectioa Comm Itromm,
FAR WATER SIMPLY WBI,t.S ONLY; 1636 Mau flervlet•Center,lltale h,NC 276WI636
13a,Y(eM(pm) 1 Q Method or test:, =4c.FPS W ALU Agob A 1nped196 At to adtution to aging the form to
ttte atldras(cs) above, olno nubmit one copy of this form wihhin 30 days of
13b.DldnWon type: ..... Ama>trrit,,,�,,d o �p completion of well c miructitm to the county health department of the county
where cotistructed.
Fenn OW-1 7- / Nanh Comlino DNpsrbaant of Nnvltonmettal Quality.Division or Water itcaaam Revived 2•22-2016