GW1-2022-03898_Well Construction - GW1_20220412

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I.Well Cbntmver Inthratotiam `f
Wall Canhaotor Nomo O
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NC Wall Comnutw Coninan►mn 1Wimhar
Cannady Bathers Well Drilling Inc. ,
Catnpany Nome Af
4.Well Construction Pertnit a:
LUl all ap ilvable imll ca,ut„lCttan „It n.e, auopt gate, 'orlatee,vej R. R. n,
3.Well Use(cheek vnell utv)t n. R, ta,
(vatw3upply Wallt r
UjAgnutiltuml R. R. a in. o p.pw+'
JAquirerTast
ttlt►rtnl(Nminalcoaling supply) OResidtmtial Waicr Supply(single) R. 0 I Y d G
ustrianommercioi C)RcAdentlat Worn Supply(shored)
AS
on
Ater Supply :
nStorin RcrouW �, R.
an Wall,
utror Recharge �t3reurxiwator Remediatitm rt.
ulfbr Stomp and Recovery C)Salinity Barrier
urimonlal Technology (3subsidame Control R. R.thertnal(Closed loop)
th ai(HgAUgLbo1lg&Ratu explain mots 0
4.Date Well(s)Completed-3 �� 'd� WEII 11M OR. fL
so.Wall t.ocatlont
Faollily/QwnrrName Fsallitylt)N(ifapplfwb�) R, R. R F,
phyrleal Addreu,Chy.and Zip jd/
County thual tdgMlites W No.(FIN) -^,
lul
sb.Latitude and tongitudo in dogrooshninotcs/secottds or daclmai degrees:
(If wall hold,ono IaViong Is sutmelont) E1.t7arttttcaHani
007
0.11tort)the Wett( )D nett or Orrompvrary rumof o omcagar tktc
Ry algning thls J �►hvr*cYwti,$'thou the+etflh)mu Amm)caktrixtr+f In occor4f"
7.15 this a repair to an exhi ttg vtndir ®Yes or Ai� uilh rx Nc ".A1 110 or tJA NCAG OTC A16A Wa7!Cbnttnnvlou Srrar/arrb and fiar a
!f thls if i►IV1Htlr,fill oat 1,roun n+rll(OalflUNtDN hirblrautPon and mrplatn the nature q/tht M.o !!di rvroM ho him f1J' Ided to&sivil oKvw.
ropnlr under till rvararAt seclten&o„the bath allho fart.
23,tiiltc dlttgrAm or Wddltronat weft dctallst
B.For Cooproba/DFfr or Clowd•L.00p Geollar ml We s having the some You may use the back or this pagtt to provide additional vaeil site details or well
construction,only I OW-1 is needed. indicate TOTAi.NUMBSR of wells connnsu,xion details. You may aim attach additional pages irnecawry.
drilled: Q
9.Total well depth btdow land surthat ) MR Submit this Rbm within 30 days of camptotion of wail
Nor►nwhole iivilr 101 all depths ffdobronl fammpl& W' IF oon;ft on to the allowing:
10.Static Water level below top of emong(„ (f1•) Divlrlon of Water tiewurt>eo,tnfortntttton Pteet atrtg tJniti
(/nn►er fort is abota t nshet,wr"c" 1617 mail Servieo Centel',RAMP,NC 27699.1617
11.Borehole diameters ► l Rotary
, 34b.� l in eddltion to wdW the form to the ed(h=in aka
13.Well eonstraallon tome., Rota•,d..,�..,,� �at.��m to�gto w copy or this�tbrm within 30 days or completion or wc)I
(Lo.auger,rotary,cable,41=1 push,eta.)
Dlvlalon of Water Rest►nttesa►Utxxdt rgmad iR{t►etion Cotetrad Program.
FAR WATER SUPPLY WELLS ONLYt 16M Mail&rAce C:c»ter,Raleigh,NC 27ti9 IUS
13n.Yiatd(ROM)...,_,�,�..,_,,,,. Method of tat: ,,��,,�,,. 34e.EK *&.Jlll sen t In addition to ding the form to
0 I�1� t addraaa(w) ve, alm eu "'"�Qno copy of this Amn whbin 30 days of
13b.Msinf�eMMn type% Aalauntt v construct completion of wets ion to the county health dopaWmcnt or the county
whore contracted.
nn Fe t)WI Nosh Lemlino Dolminont of 0nvironmental Quilly•Divislon of water Rowumi Raviwd 3 22•1016