GW1-2023-02343_Well Construction - GW1_20230331

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NC Well Coota CettilleaUenNumber R.(6.'•.01kSERCRSLYO'(16ir"idHeHitilVillitOliltiNEROfa"' .btEk.
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r,`'� 6 i :1 �tIVEAR. Goa. R therneil:erase drl$6a1.� +ec,:u= °_—<
• 2.Well Construction Permits: ! FROM TO MU TMOOL:6s NATIMIAL
tfordicppiimb/emlleommrnonprmdcr pe rife.Cmmy.Sicre.Variance,arc)- ft. tr. im
3.Well Use patinause): tr. fr. to
Tm[CIOIESS L MATS
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jGeothermal(RentinE/Ceoling Supply) t�1' - .ential Water Supply(single) re. R tn. - _
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pirrigetion •PROM TO MATER SMPLACr1HBNTS1EfROD&AMOUNT
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ahlanitraing CIaec.ovelY It . ft.Injection Well: _ ft.
• ['AguierRechargo EiGroundwaterRemedietioa •
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4.Date WeH(s}C.ampltted: :3 Well IDq� gOft. ',go n 67"ces+erl .
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Sb.Latitude and longitude in degrseslminuteslseconds or decimal degrees:
Resell Sett ass Wang isJIM:ieat) 22.Certification: 46 g a- 'a JJ��3 S% yl9G N V 1 a�'2 is 70 W - -iri / k `//// i 3 — )o -6))6.T(ere)the wel(s) Permeaent or [Temporary Sipper:a cmfled well Comm Date
8y tlgnin5 Ws farm IlaN6y cart*liar the u-e1!(e)Ira[(irero)mmaucred a,aoroidancs
a 7.Its this a repair to an existing well DYea or o wan HA MAC or Ili 11CAC 02C.0200 WeliCoartrueuonSiaada de aaddmr a
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war under VImaark action Irani&tack ofrMrfann:. -
23:Site diagram or additional wa details:
8.For Geoprobe!DPT or Closed•Loop Geothermal Wells having theamna You may use the beck of this page to provide additional well Site details or well
• construction,only 1GW-lisneeded.Indicat:TOTAL,NUMfl tofaxtts coastnuGondetails.You may also Mach additional pap ifnecessary.
drilled: gitiMSTTAI.INSTRII([ -
9.Toter well depth below land sDriace: ? a G' (It) 24a.For All Wells: Submit this form within 30
Formelap(eycile!Wail deAzfld ruu(e�mp►e• eliO•aad2®100) days of completion of watt
construction tits following:
M.Static water Wet below top of casing: GO It.
i/r,areri+ratuahovaaar<a$eae+� ( } Division of Water Resources.Information ProcessingUntt
1617 Mait Service Cchfer,Raleigh,NC 27699-1617 - -
11.11orehole diameter, lag pft_ (in) 24b,jror Infection Welly In addition to sending the&unto the address in 24e •
12.Well construction method: r KO Oa i ( - above,also submit one copy of this Than within 30 days of completion of well
(i.e.soar miry.cable,dadpath.eta) l�ii constNctionto the foliotving
Division al Water Ramreer,Underground Injection Control Program,
FQR WATER SUPPLY WELLS ONLY: i636 Mail Service Centel-,Raleigh,NC27699;1636
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13e.Yield(gp►n) .20 Method of test: ;lIpe 4ur.�..a 2�ie.For Water Sunnly&Infection Wells: In addition to sending the[otm to
1 the address on address(es)above.also submit e copy of this form Within 30 days of
13b.Disinfection type: f& Amount. a' Gam/ completion of wall construction to the cotprty health depamnent of the county
- whereconetructed.
Form GW 1 NatbCaanlhe ktonalassafEavusneesrslQvaliry-D;OWofWotaRoomccs Revised2.222016-
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