GW1-2022-09073_Well Construction - GW1_20220923

Jan. 24. 2018 10:58AM Env. Health . ! No. 6111 P: i
WELL CONSTRII MON RECORD&M 1) Far3aternet Use only
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NC en Comm rCeeilios MISIMber SEP ',.2022 f 11. n
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2.Well Construction ParaitB: z io
Lluall appttao(rtereel/eomauetioapemrfn pa IM O-0:ssata Yorrmttat6 ae)' tG a. In.
3.Wdl Use(eheekwell use): n. rr, to.
Wuerbapptq eti: .iti —_:���.s�:,_. - - - 'u•• ---�.'"�rs.•� .
Agricuttwal QMwieipaUPahlit 0 tL lL k io.
Geothermal(8mtins Caoling Supply) E)IRSldeatiat Water Supply(single) IL R 1% .
_Industrial/Commaciol QResidential Water Supply(SMtod)
Irri Gon t MMERML I OFMAGAMR3s o
Mon.Water Supply Welk r` m iN .c
vc%L tat,
Monitoring 0R=M 1L rL
7njLe
_ AquiferRtxltorge �]GmttedwaterRemcditrtion
Aquifer Stwop and Baovery Q8alinityBonier
a�r$on- .
_Aqu&Test QStaormter Maiaage IL rt
&Perimental Techaoingrr 13sahsidence Control m tt
Geothermal(Closed Loop). - _
, QTrecer
Gea►hetmet Cook ReranL E30dwLwqMaaderA21 Remoft tL fi -e de C1CY
4.Dote Will(s)Completed:Wert ID# s• ft (��,�f ,
5a.WellLoeaflom � � ;G�,"y^��•�
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Fta7ity/OvtnerNeoa PaedibrlDrl(if6yytteabb) rt n
c Rd.ti�� 4f' d Pam^
hays• Ad&w;Car,and p m rt6
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cmw pe+eetidemi5eat;aaNa(PIN)
Sh.Latitude and lottghtle 1n degrees/miontedieeonds or decimal degrees: P77-
Orwell 22.Cer6GeatioarcJ-
�Gol N 7S & 7 4(ar0 w hL IAA
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6.Is(an)tbeweMs) Permanent or QTemparuq sty wencamaaer note
By AiXdV thisIbraa I hereby evo rhm the moll()tar 6,M)awamer a M OMMonar
7.If;this*repair to an ealsthtg wet QYes or Me wi*ISA MAC 010.0100 at M"01C.0280 Aldo Comawwon arm*W*ad that a
4rft Is a rVakjW wd hvowi w&eaqmwaa L*rwim aWwVkm As non afdro awofft„wdMbunFor0dmOnw(towns.
mp irwdgi]/rra wh wear Oran do hadojdbsjorm. 23.Site diagram or addition*(well detaiis:
L For Geoprobe/M or Closed-Loop Geothermal Wills having the tame You may to ohs:beck of title page to provide additional=11*ire details or welt
eorsbuetion,ottly 1 GW-I is needed.indicate TOTAL NUMM of v h eomtntctimt details.You may also ettach additional pages ifnecessary.
drilled SUI M AL I1MR11 C77pNS
9.Total well depth below land sort mr ) 242.For All Wells: Sttbttrtt 06 6orca vuithut 30
Ana uWytevsniture►ldepd..ry/dlfoa,rfe p+e•3(�20D' /i,�/100} corstrucdmto the fi lownc i days ofiompktton of wool
10.St*dc tr*ter lever below rop oteasilg: Dlristoa of Water Raouree%Inrorm*tron Proctoug Valk
Ijrerrerteroettraaorwarriagure �' 1817.fsitService`Cethr,Rald2b,MC27699-1617
1L Borehole dnttneter ,—'(In.)
246 Fer-Inteetton W rq'addiNoa t0 9tardnrg the fattnto the address in 24a
12.Well Construction method: 04y' 111)(I ,elan t:olrmit one CW of this firm within 30 days of completion of well
f 88--fOINY.CAk&M PMb6 eta) tMnatiento the following j
Dbiden otwater ResoarcM Underground injection Control Program,
FQR WATER SUPPLY WBQLLS QPiI.Y: L 1636 Mad Service Cmtei•,Raleigh,NC 27699-1636
13L Yield(gptn) y Method of tat•. �. 24e.For Water Sunnty&Ielecdon WeOa: br addition to sending the form to
the address(as)above,also submit am copy of this fam vtitbin 30 dogs of
13h.Diehtteetlon type:-41'1Amount. a ��s completion of trail consuuction to the county health department of the county
whom eoumrucled.
FarmcW I xoRhtDcpa,tezmrarEmenameaaelQmI;ry-Dnniaaorwetuxcr�tnim tlevisod2-22-2oI6