GW1-2022-09568_Well Construction - GW1_20221021

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HELLL CQNLMUU TION RECORD(cw 1) For Ional use on y:
1.Well Contracto Information:
J 6A 14.WATER I
well eel Name MOM
m Dr�CRil1T01.1
311-0
15.OWO CASM t6for edweBa (Mrs"
mom I DIAndE En f nuclifts1YrX1 IA1,
eay ft. I35 ft.
camp
30,1104ER (M T JBING dosed-i
2.Well Coustraedon Permit#: FM
List aU applicable-wfi aonarmdtion permits C3.e.WC,CounW.Aft,Varlanas.etc.) Dt. ft. is.
3.Well Use(check wen use): IL ft. Im
Water Supply Weil: 1'
FROM If—ITO 1 DIAMETER 'lawlM,E I IMATERrbfi
gllt:ttlttlrat y ttIIlCtpaltYitbtiC t0.
r=hViathuiomn
ud(HoatinwCooling Supply) Ratdential Water SuWy(single) ft �,oammezv4d 13Rc�idendai Water Supply(sbered) IL
Non-Witter Supply Wei: ® IL Z,g IL C," a6V-Ov.ty
ve9 it. ft.
MUMS
ft, ft.
Aquifer Recharge OGroundwater Remediation
Aquifer Storage and Recovery t115alinity Battles mi :-writ=- -' M T IAL EMPI.ACBNIM
Aquifer Test 08tormwater Dralmnage %
Experimental Technology (3Sobsidence Control
Geothermal(Closed Loop) QTiacer 20 a at tf
Geothettaal ItenlDm Other lataunder#21 ltelnatics D ft, 0-6 tw
4.Date Wells)Completed: Z' Wen W# o�S 3 Ifo $ rhi t
IL s.
Facitityll)vaner Neme Facility IDA(if applicable) ft ft G 6a tom-'
Physical AddtaM Q%and Zip ft. ft.
-�dj a Kt In.
Coueiy Parcel IdeiiScationNo.(PIN) o. r� uf*
5b.Latitude and tongttude to degrees/mtnutealseconds or decimal degrees: m 1'
(iNCII field,one lat/tang is s iffidm* 2L Cardficadon:
--N W jL4 �2
6.b(are)the wells)�iPermattent or J>mprary Signanua f Cemtitied Wen Contractor Due
By slVdog+k16►'na I hereby can*that the u,11(s)un&vv)constructed In accordance
7.Is this a repair to an existing well: 13Yes or G�lo with 15A NCAC 02C.0100 or IJA NCAC 02C.0200 OW1 Coaainobn Statdarb and that o
tfdis is a rrpa niV ourk mm well construction bp*rarn adm and explain the nature gf the C09#efthis record has hmsprovNed to the sell owner.
rgWr=der#21 mmarftaeedion or an the backoftkisfmm
&For GeoprobelAPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to;provide additional welt site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wens construction details. You may also attich'additional pages if nem my.
dril d: l 1 Q MAL jN�1•�ONS
9.Totem well depth below load surface: J OL) 24a. FA All a; Submit this tam'within 30 days of completion of well
For multipk wells liar aU depths('dif f wu(example-3®100'and 2@100)use (ft:) construction to the foltoaving:
V%Stage water laud bet top of casing. Division of Water Resources,Information Proceming Unit,
jf xvtrer level is obave cas8►&nx +^ 1617 Mail Service Cent,Rddgk NC 1709-1617
11.BoreWe diameter: !E 0114 24b.ftr ielection Weir in additions to sm&%the form to the address in 24a
17.Well eonstritemm method: 911, 1'-0`�a rY above,also submit one copy of"form within 30 days of completion of well
(Le.a .mosey.cable,ditect pub,ern.) constructionstrnction to the fonowing
nger.
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground In jatlon Control Pcagratu,
1636 Nd Service Center,Ram,NC 2709.1636
13a.Yield(gm) Method of test: Ub') 24c.For Water Sung Lv&Inieetioa Weis: In addition to sending the farm to
,L I�- the addresses) above, also submit one copy of this form within 30 days of
13b.Dl�nfecHon type: Amount: ___- cotnoletion of well construction to the county health deuartmem of the emmty
_ with- ere congtrum&