GW1-2022-07756_Well Construction - GW1_20220819

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Jan- 29. 2018 10:58AM Env. Health No. 6711 P. 1
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WELL CONSTRUCTIO RECORri„(GW it Far el se yr .
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Z.Wel1 Construed"Perwt8: o -
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ecdon ell:
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liaperimenrelTechnology Qstdtsidencecontrol d
Geothermal(Closed Loop)• QTracer
Geod:ermet(1;<eating/(`ool iig Ren"LE30iberLdVIM uoderd21 Rerrmrb)
itc tf: , 7-5-'
4.Date Well(s)Completed:tl.(._..Qr.a.well UN a b e�'7iC
5a.Well Location: h o
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pirys,csi Add,est,cd,sad to M
C�a• pa�lfdemifieatioaIlo(PIN)
Sb.Latitude and lot ghtle to degftmminutes/seconds ar dedtmd degtees;
(itwau IIda.ooetarllangisrnt6etead 22.Certilln5an: t
6.1a(are)The treU(s) Permencnt or QTetnporary 9tpurmeo erteedwauConaacrm Date
7.is ihls a repa(r t0 an eatatlttg well: 13yes or Br b0++nd1 tlatjotn l6eroby !far the teli(d toe(f.ers)ntmatnad oaodenas
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jane .�uexesco2e.o/�or/�,i,vcieo�e.a�oo iimca ,osa,,>do►damnumra(r�+Is4arrpal,Jlparobroe,wdrmm�uara�rtmta,mdaepogrrheDam0,,b cWOfftAwMA1tb=FOrtaadm the mponmr.
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23.Site diagram or additional knell ddans:
L For GeoprobelDPT or Qosed•Loop Geogarstral WeM having the&trot You mw uro ft back of this page to provide mmwoa d well sits details or well
cowbuctiO4,0nly1rJW-1tsmded_IadiMe TOTAL NUMBB dwells w hUdiondetatk YOU tnagalwaltaehaddificnalpagwifnecmnry.
drilled:
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9.Total well depth below lead sarrmt dk) a Fbrmrtrrpisvdk/trra►Idepd,.Jepletenrresae�►e•3�ipd•�d1®�pp) �SE..tu�w�: Submit this front V'Ad n 30 days otaMietion of well
construction to the fouowiag:
10.Static Water level below top of eaiag: (ft) Ditratotr of Watet Rao
#'VMrlat*t trabmman&&urn+' urea,Informailon proeessiug Un%
1617 Mail Service Ccbtca Rakilk NC 276MI617
1L Boreh diameter.-_
als diamet —.a- •(ip,)
j') �. 9�,jQ(� 11 yp� in ttdditi0ato atatdutg the fntmtn cite address is 24a
II WtH ronlltncnob method:_ '•a.1" ove,ab also submit ono only of this fgm'wititm 30 days of completion of well
Cu mss*�c table.&W pntA aa) ram--- construction to the Spllowmg:
FOR WATER SUPPLY WIUS ONLY: Divirion ofwater Resources,UbdetgmM bdeEden tamrol ProVM
1636 Mail Service Center,Raleigh,NC 2709-196
lea.Yield c
tCAm) b?elhod of tat•. , >S 24c.For water tinnWv&Inteenon We t.; In addition to sendiag the fomt to
13b.Dislnfeenen woft /t thead '(�)above, d-submit one copy of this tarn wiftrin 30 deys of
Atnonrn completIaa of well eongmlion to the county h alth depanment of the cannty
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