GW1-2022-10218_Well Construction - GW1_20221111

V_W L CONSTRUCTION RECORD For Utl[rslai Use ONLY:
IS tbrm can tic used for amp or multiple wells j
L well Contractor lnkwmmion: l
w i
M TO D
Wen CowrMtorName E C E I I Q �' G �' I1'►�'CoA
i V 0 �'' no Q' S"Sk. 4
NCWdiCondactorCalffloaiioaNutuber Nov 1 � 2�22 1xtlulrelteAsutrr sm ffi LINER a bee
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CompenylQeme tn 'wa'DOG Oli
091TU ULUM MA
2.Wdl Construction Permit ft. 375 to tt
Liu all elrplfatbk well perW9 G.e.Corm4V Seine, ectlolr elcJ fr tt. in.
3.Well U*(c11eek weR MP l7
T D tt1AT8t7� MATMMAL
Water aUs a !w Q R' h1' !�
OAgricultural i]MunictpaltPublic
Q()"t WnW(Heotind/Coolf-5 S-Pply) *eaideadat WateravflY(al-se) 11011 So 1% J4 �l40 1 PVC
CllndastrieUCommeroial OPWide fial Water SDPPIY(shared) to ertvur
To A Teti SM I AC atrr PWrMoD&AMOXOM
ObTigglan O tt 8. Rot1 Gb
Non-Water Supply wall: R IL
ca.&M iwiea; aReeovery fit tt
It
OAgWfbr ROCWrge aGroundwater Ratuftl ion l9. PA able
T6 L Bl11l tBNT
❑Aquifer 9tomV and Recovery Cluini y Ranier n u,
OAquifIr Test OStmmwataF IJ[ainags fL B,
1394 rifnental 4bchrtology ❑Subsidefma Control ,2R' attack .Id-Ma
E30C helmai(Closed Loop). OTmcvt FROM To DroCBtr7tort coror ► ew
t7t11aodtermal Head ool' Ratum t1UAur underayS"1 Remarks R' /O R GL
4.Data wells)Completed:/O- ' 1DtY /a ft 2.0 S
tt S S t4
SL Wen JAC ADD: It tt ,d
3oS tNr4u_ v rr. 6 2� t+. I CL
h Faaift/OwnerName FauilitylDq(ifttpplicabio)
ra 2 �' "70 ft- MQ> CnID fCS&1L 6t�.
S 9 fitmc- 'roucrbat. �► ?F AL t:. 7p lL 80 tL < t 16 sots
PbpW AddMt Cfty, Zip 2.7 d 4� EL 1tE
_pE1�61utt�s�1L4 —6 Cl/I
cwq Parcel Ideattfleation No.(I?I1V)
ft tieitituda Md 1400 tale lB dcgretIIWuutra/aeconde or deelmai degrees: 2L CertifttlI n:
(ifweli flofd,one Wong fr.sumcfent)
�G ltll�fi�9 x —7G. 37GG/ w rb• �fi,,�l Io-a,a��,
- SsofCorefCuid well Contractor Date
6.is(are)tha veil(®)! 13pu anent or ❑Temporary lay,,Ira Alribm,I kry*eer0 rhos dre sent+cur AMV)roc bwbd hr aemrdmx+r
sskh ISANCAC 02C.0100 or 1SA NCAC 02C.02M rinse Conaf dkft&X dw*mtd drat a
7.L then a reps&to an existing well: Oyes or 10 copy Oft record has bwpraW*d to the well atncer
{ffhtt It anpolr,/dl era A wtn veffewv w&wrl�rmados andOvIds fhs»mtoaOffba
„v ar,vMkr eat nMMM6Ofteon or on&C a.ek.J&&fv . 23.ttite dlrfgt'am or additional well dehlls:
You may use the back of this page to provide additional well site details or welt
L Number of wtils constructed. cons ucdon detar'ls. You may also attach additional pages if necessary.
For mu*u frdeerlon or rwmwarer sogy wafts onywak am tame csnw wOvm you cm SUBMITTAL Ia(3T1TCTiQIYS
rnbiph mre,f6vx.
9.Total well depth below land aorfaea: „/Z� IFk) 246.For AD Wpb Submit!this fom wlttlin 30 days of complt',tltln of Well
For midtfpfe welt f t aff depuht construction to the following:
...•1a Static water level below top of easing:,,, L (R.) DlvWon otWater Resomrcaa,]nlbrmation PrucesOng Unit,
r„ar&-Wt,abaft atlas,My»+_ 1617 11611 Serviee Center,Rate A NC 276994617
11.Borehole diameter. 7 7�R {in.) Ub.Fist Infection VjIh ONLY: ID addition to standing the form to the address in
24a above, alao submit a oapy;of this form within 30 days of completion of well
s�.w.naaaaavatlao.�aa�,rQ/(� ,� OTh2y canstfuctianto the foliowing:
(144 MW'1vWy,ate,db=t Pmb'cw') Division of Water R"ourees,Underground Injeetion Control Program,
FOR WATER SUPPLY WELLS ONLY: 16M Mail 9ervide Center,Belelgb,NC 2709-16M
aL yidd(epmp 126 GIP►rt .daunt, CE"iT ,e 240•Foe'water&Mow d lnieedm WtW:
Also aubmh one oopy of dus'& u vA&6 30 days of oernpletion of
13L DS>dafsedon type*H Tq Ar lonnt won oonstruccien to the county healdr deparoaent of the cou ny where
consbucted. .
Fora GWl Notch Carolina Dep nmetof EnviromM and N&MI Resources—Dtvwm ofvV4w Rasolnct s Itovtsed August 2013