GW1-2022-08128_Well Construction - GW1_20220906

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Nc Wall Coaftctor Certification Number
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water Won: FROM-- TO DE&HEM &OT tumzz MA
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thermal(HeatinIVIOCKAiliff SUPPI-.0 biresidential.Water Supply(single)
(!Residential Water S-apply(sheared)
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Supply Won:
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ubsilmor Control tL
Piperimental Technoli)gy
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Ai Date Well(s)Completail: Welk TDO
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CARJUJI Pv=I Identificatioa No.(IDC!
5b.Ladtade and longitude In degmfifirflaubealsectinds or dedmal degr"I:
(if wall freld.ace lavloz%is tufficilpt) 22.Cerdftallow.
SiFlatUff ofCeftified Well Can I
6.liKors)&e wello)E)Pennavest or OTewporw7
By sPgnbv rhiy jbm I 1--p49;cerejN drat the wwflja)um(Wgre,)contiructed In oxordanc-g
7.Is this a repair to AnW2fttv'rell: 0yes orJVNO �vvh 1M Ns. C 02C.,0I(90 or 15A IVCAC 02C,0200 WrYtropuln<non Stanclardr and that
#Iihir&a repot.ftH aaa kwm wil cww&urtwn rr f xwurilon aw e3gua in Me santre Of(4e LVPY of this reccrti 1"v been provkw to the well P.Iser-
repWr under 021 rawoft secdon or on the baat qjAtvybPm.
23.She dbqpmm or adjIftnal weR deftils:
R.For Geoprobe/DPT or Closod-Loop freathernia)Wells having the same You mav,tux the back of this p&W to provide additional well site details or wet
c4onstruction,0:1 Vw_I is'amded. ln&cate TOTAL.NUMBER of wells construction details. Yoti nuy also attach additional pa8es ifnecemapy,
drilled:—
9.TOW well depth below Mad sarluee- Ue. Ift1h. Submit this f6im within 30 eAys of completion of wcil
I Far n"*k war A"441 Amda 9,14fferext(—pk-3@200 wad�2@1001) construction to the following:
It.Siatic e46i levei below top of casiog: DMdon OfWa tee r Rejources,Wommdon.Processift,Unit,
lfwwgealevvl b above oavft,uge
DI Borwialet.dlsaaeter (lee) -&QQ par Itffieetfa+ra Wells: In aMuiot!to sending she.form to the address,in 24
14n.also.rsdn.0 one c,-
spy of ftmn within 30 mays ofco-,-
iz-vol awthod: JR, 'el Construction to the following:
#a--W.toWy.cabk,�Abectpwk aft.)
DtAvioi of Waler'Kawura&Ua'derVound Injection Control Program,'
FoR WATER S,UIPIPL V WELLS 40N),Y. 1636 IN[ad Sefvice'Ctnter,RmkA&,NC 276",.1636
43a.Yield OW) -Method of test: Z" E&L,EA ,�u In addition to tending the'faint to
the aftuw(e).abom-aiso subW' C'JPy Of this form within 30 days of
13b,DhWattion t)l)*- Amount: completion of well corutruction w' the county health department of the cwmry
Wbere Constructed,
Form OW-3 N(r.1h Carolina D00artment of Envintimental Quality..Division of Water Resourcas Revised 2-22-2016