GW1--03556_Well Construction - GW1_20230519

� < =�•—,.—v%-�rl:1--_;,3 .tr�.,�a� p T prvq(7� can y,
o
I.Well Coatraetorlhibrmatioo:
C;ai8 emu Bin 14.VIATM7A)M�
VJcllConnactOrNamciL -IL
&Ro6t T® DESCA�I®let
45I B-R1 S !�
NCWeUCantmciarCdffitsiionNumtrer.
15.®tITI;RCA.ffiilG multi-f ssd:ca :®IRL1R>I;R b
Aqua®dill,Inc. -mom
Dfi T®OMW 9fATEH6AG::.. ..f
Ca v-yName
j (� 16.II�hIE�CA59Pt1G;OB3'TU�Ii'IG Ylffiamaldose�loo
2.Well Construction$'erlo&& x� THtCEaWM MATWIKAL
ListOUapplku6leKaUcotcsttuclionp�rttits a.UICCo+mt3:Stale-YarinatKde-) -EL M.
3.Well Use(che&wen use): & In ,
[1I
uppFROM TD DmAldam SLOTSUZ THICNNM Lltttt & zu
ermal(Ratinac-oling&44&y) Reaatlal.Wa,supPty(Mile)tiaUC1LM®�Toa TO X&TE fAL. ..EaD'Lied 1atEd7toQ A. .0
ter oting Recovery n Well:
erRechatgeGmundwaterRetnediation SAR�1CttAi/�9:erStniageandRecavery Saliairylianier FRant< T+o atA]Rrsa.ferTnst �5hamnvaterI)taioae enhITecbnology 'aSubO=c*Comml emaal(C1osdIoop) �Ttac� zu:Dlt��t1YCF,�rde5cuada3ttonaa'dletvtfhennalWeatln CoolingRetams)s ; thiter( labaunder 2lRemadss Fttoat sn »camaaoyv(®mr acuhodf mie ete
4.Dabe�4tdt(s)Completed: 2 2 : .WeUHW -
Sa.Wellbocation: $• � `_ �-• -
y
FncOityfOwaQNamc A f ,
Faci}ity lI?t#of nypisgble)
PhysiedAd&-%Coy,-&2!p !C`
CMty i?ateelldP^*fi�*��No(Plt�
56.batiRndeand lo�hade in deg}ecslminnPestsedAands or detimai degrtn+ss _ .
771
Cfwcll ficld,:anc.laVloDf;is suffcieot} 2L Cermcation:
SIMMIb[Q arcex6fiet Well emtrdctor Date _
6.Is[are)tl>ie wa(s).. ermanent: or MT--porgy
Slgnir{g dttsforrn,l hereby certljl•that the ive/l(s)i�as.(sswsa)constmcted b a=ardaece
svlth 13ANCAC03C.0100 crISANCACO2C.02QO WeU.Conmuctlos Stwdards and flint a
7.I5 tills a re - /D en existing weIl: I,: Or u ca o thareomd has berg 1a theirdl emmm
Ififti$a,Twa&,,JID nut bwwnWW ujarcratlonandevialnlbersotmeajrhe PYf Pr
repair an,rffl2lran See tlonGranthebat k'ofRtxsfQmt 23:Sitsdiageauaoraddltionalwe]Hde .
Wells ltagmg the seine You may use the back of this page.to•pr6vidii additional well-site details.or well
B.For Geapmbe+7D?T-or Ctose&Y&Op Geotbetmal consitaction demels.Yonn ay elm adwhadditionalpaga ifnwmsiny.
Cawtinetion.only I GW-I isaeeded IndimtsTpT11I NiIMBEllofwells
/ SUB111➢11TAI.3QWRIUt'➢•ONS
9:2 otal well depth below land smta L�Z 0L) 242.For AliWees: Submit this•foma within.30 days of completion of well
FarmaldplewzUsUs4 d tf� (�""p�`3�D,andIQl003 constroctionto the MOWing:
t� (ft:) Division orwater Resoursm,Information Pra u
gti.StatiewaYer level below bop of esalug: 16171 hit Service Center,Ralelgb,NC 27694 16 7�
If,.ter levzl isabmveeasing.sae
11.Darehole dts r. 24b.F or Aniecdon Wells.In addition to-sending the form to the address in 24a
above,him submit:m®COPY of ft form-within 30 days-of completion of well
12 Wes Construction medwd-�-� ►coon to the following
[se.a°Se,ia�s:�iS dQ�'Fffi��I d9ivcsiom ofWater Res ,dlTaderga'onnd InJestlon Conb^oYPsogeana,
1636 MQ Servi-Cetiite4 Rtiie�li NC 2769-P-1636
p�H�1ATEI35IIPI"�I'�9RI+i.S®L�YI: �j p '.
1 �9 .lfGtGl(e� 24c.For Wnig.Stela Laiettion 9Ur�91se Id addition to sendffig the foim to
13s.Yield(ggm) 1 sHtOd� � We (es)above,8150 submit one copy of tbls fail:witbm 30 days of
completion of well caastntetion to the county heaUn department of the county
23Fa lDisitafectiOa type: wbete conshucted.
ofFnvimammml Qoality-DivWmn ofWaterAesm=es
FamaliiW-1 NatthCamlioaBtP'�°t Revaed2�22-aO16