GW1-2022-05441_Well Construction - GW1_20220607

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2.wen Construction Permit 6: FROM to Dr T� NXIERML
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Commercial [�Rasideatiat Water Supply(shared)
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5h,latitude and lottgltnde to dtgrees/minutea/secouds or decimal degrees:
`/ cir®alt9eld.aat+tsNangissu6rawty 22.Cerfirm ion: .�� ��- k PRO•T "I± UNI
6.1a(an)fhewelt(s) Permanent or [�Temporaty Spitum ofiewifiedWellConasctor i Date
By zpning ddi fte ft I hereby em*rhor the w ff(t)tsar"e)eautotufed at accot&M
7.Is this a repair to an existing weft: QYes or QNo with 1SAMAC 02C.0100 ar l3A NCAC 02C.0100 WeBCb w terfon MaaAa&and that A
If Mugrrarepai.,J1(lad blame wag awt uaml,tnfinearmnmaterplaet the rmfanof , °DF ofthu xedhub"11,11MY tdrorhsfrdlmmcr.
repairw,der 1MnauhTamanstun the baekofftform.
23.Site diagram or additional well details:
L For Geoprobe/DPT or Oosed•Loop Geothermal Wells having the same You.r► y vso the bark of this page to'provide additional well site details or well
con sftwion,only 1 GW 1 is needed.Indicate TOTAL NUMM ofwa& conitmcdoa details.You map also attach additional pages if necessary.
drilled SU NTrrTAL 1NSTR1/(`l7t N�S
9.Total well depth below band surface: �/ S fh) 2da. For all Was; Submit this fom1 within 30 days of completion of woll
Formafaylersf►aGsrafidepdu;Jd e,w(ezampta.3(d�T00 andl�l0tr) ronsti a antoamta agking:
10.Static water level below top of casing: (R•) Dlvisfoa of Water Resources,Informntlon Proeessiag Chit;
#wmr toot trabm*aaWg are+ 1617 Mail Service Cohfer,Ratefgh,NC 27699-1617
11.Borehole diameter.qZq (11) s�o�
246.For inlectlon Wells: fn addition to the fatnrto the address in 24a
12.Well eonstruellon method: 104,r l' _ above,also submit one copy of this 1bun within 30 days of completion of well
(Le sago,safety,eabty dual pntb,eta) conssteuction to the following:
: Division of Water Resources,Underground to jeetton Control Program,
FORWtlTFR SU1rPLY WELLS G11II,Y 1636 Mail Service Ceatei•,Raleigh,NC 276991636
13a.Yield(Lem) a Method of test. ij,"Or 24e.For Water Sunnly&Infeettoi wells: In addition to sending the form to
/� the address e,es)abov arm submit one copy of this bm within 30 dos of
13h.Distnfectlon f!11M 1 f Amenur. C'-15 completion of well construction to tho:commy faith depanment of the mnnry
where eoushttcted.
Fome(iW 1 Ne t?4ot,aaDepnnmeatatFsv;,00mearai(haliry-Ifivi:ionofWnaRmomen Revited2-22-2016'
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