GW1-2022-09597_Well Construction - GW1_20221021

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1.Well Cautractor Wornuition:
'WATER
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well Conoc A"Nam FROM ON
ft.9-).t d b
NC Well.caftrar-mvrj"fifrotimMtmhx !.-
�Q + is o �91NG or o S�waHe OR L21i$A _^--
./ 1 4l V� s FROM TO D
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r _361MUCASMaRUMNO 4d dML4ft
2.Weil Construction Permit#: �A! LO s FROM
ListaUWUaobls-iwellaomftadonpenmAs(le.Uld~Cauno..Mate.Variance,Mj it. ft. fa
3.Well Use(ebeck well use): ft ft. ta.
Water supply Well: 17�
.—.---•-.-.,_. mac.. . . ,_. BROM TQ_.-.-.-._...1DtAMBTPB SIeOiBi?E iBtCdQVE4a MAr_-Ar
jA4,qq
(Heating(Cooling Supply) Romentfai Watea supply(shtgte) R fL
Qitesidential Water Supply(shared)
Wadnn UNrSupplyWell: MLani g�v % ft.efflon e t
ufibrReeharge QGrroturdwater Rerealiation
aenage anurvim eey Ljoalmityfianter FR M E11fPt.Auifer Test QStottnwaterDrainage tt. �pedmental Technology QSubs9d m Controlot umml(Closed loop) QTracerwletmalMetW—COOV2ARenton130ther lain wider#21 Remarks M
o IL ft:
d.Date Weil(s)Compieteds Weil ID# tt: 30 ft i G
$a.Well La "vV ft_ IL
�- TA ft fY.
Facility ame FPO P%
i' Facility M#(if aWlable) R• D• k�sue.. t
_9�� �VIU am?A �� ear 4�V� R. ft.
Pbyokd Aft as,City,and Zip J 8. n,
_Dr4h�t, a1.
Co" U Fames TdwMeadon No.(KN) DWQIO®
..� ::..�.....iu wa.Ha•ww.m.a.:�a.vwa+auass'alecvvYYb Or UCUMal Qegrees:
(ifwelt field,oae tetlloug es'sutttaiodo 22.CalMeation:
N W 7
6.L(are)the weil(s) t or T sienatulv oP ell
� � Q empnrary tiara
AY$lgnhtg this foray I hereby near the.wen($)was(wena)aoartrncted In a wnkatce 7.L this a repair to au existing weft: QYes or 6o wuh 15A NCAC 02C.0100 or 15A MAC 02C.0200 Well Constracnae&awkrdj and rho,a
Ifft t$a Muir.fly Out kw"wen cbnOrmcda fn0rtesUvn and opiakr the nanrreofthe copy ofthls rerad lea$been provided M the wall owner.
repair under#21 remarks section or on the back of this fame.
L For GeoprobeiDPT or Closed Loop Geothermal Welb having the same Y,6u mey use the back of this page to provide additional welt site details or well
cmshaction,only I QW 1 is needed. Indicate TOTAL NUMB It of wells cousttactioa details. You may also attach additional pages if necessary.
dti]led: ` S AL AVBTRUCTIONS '�
9.Total well depth below land surface: �03
an dep0m(f n (f�) Zq&p Wes. Submit this f+bmr within 30 daysof
Fln•multgdle wens et d&lmt(example- (d}200'and 2@100� m An VV eonsfru r to the following: t10.Stalk fiction of well
ir'xa�is er above
level below top of cooing:�© (fit.) Division of Water Resources,,lafot�tion ProcarrtDg Unit,
&we 1617 Mail Sw vfce Center",R11110$14 NC 17699/617
31. �'�--: `"'•j 246.For`inieeflon"fVdls: is edition to setriimg the£arm to the address in 24a
12.well contraction method:__Q i r (,0 r y above,also submit one copy of this form within 30 days of completion of wen
(Le.ARM MMY,ea*diM PON W-) conshuction to the following:
FOR WATER SUPPLY WELLS ONLY: Dhislon a Water Resources,Unifergrouud h jectlon Central hvgran,
1636 Mail Service Ceiter,Raleigh,NC 27699-1636
13a.Yield Won) , Method attest: ® 2&For Water Srlpely r$Infectton�'WeII • Tn addition to sending the form to
13b.Dlalnfectlon type: Amount- the addmss(es)'above, also submit one copy of this form within 30 days of
completion of well constriction to the
'county health department of the county
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