GW1--03755_Well Construction - GW1_20230602

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- 2.Well Construction Permitti: +-- 'V ° ``' 1 c I FROM TO DtAMRreR TH ma= MATERIAL
lista eppliaahtexeil emuwe6anpumas IBC Cana:State,Variance.ere.)- R R in.
3.Well Use(cheeky/elluse): it. tr. to.
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Water Supply unn, r-A z �. ..s. .._ .• :=. : �=
Pidy Welk thou so -mamma sr orstzc vuctutess MATERIAL •
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Geothermal(Emting/C olag Supply) CIResidential Water Supply(single) R R to -
_lndushieUComrnaeisl DResideatial Water Supply Oared) tea(utou -=.1' i:,,-� .. -.;r .':�-4 = `'` '...
Irrigation FROM 10 V MA7ERVI , BMPLACF 15RTMErROn&.MOUND
Non•Wate Supply Wen: a' m 3, t` , 6j n) �ii* r..cvL III, h'�1 5 •
lutmimring ORseovety - R • it.
Infection Wed: _ - - ft R _ .
. AquiferRecllargo [[GroundwaterRemediation
Aquifer Stomp end Rccovery OSeh'nityBatrier FROM 70 MATERIAL EMPucciMEtlrolrrltoo
_Aquifer Test 'nStormwaterDrainage A• R
ExperimenwlTechnology Dstbsid aura Control R to
Geothemal(Closed ).. O '
Tracer 20sDEN(#IMefiifiiEirtdli niiibic s- « •
Ynat TO DIECRIPrrON(alarlar stIVrekr orabitmalel
Geothermal
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• 4.Date Well(s)Completed:S a 3 23 Wag 1DP,• 7.17 R 9u R 6"r"'is-s'`G/�'�` .
Sa.Well Location: . l/ R `VIM G/'`�`• ./r—'�'_
e5/i 4J fit n C107 - ft. ft. -r` t \.r
FaaliglOwaetName FaciiefMg(if cppueabte) in tr.
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Physical Adam;City,and 2ip - �..����R,,,..((���� ft. �. .�,�n, ::. l:Fi
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County Pszealldemitiation .(PIN) .
5b.Latitude And lot:situde to degrees/minutes/seconds or decimal degrees:
Rua Reid,ono tuAoa iesufficie� 22.ccrtifeatiun: 4,t'7 6g a'�a/J , --
. .f d 9O 6.3 c/ N /G/r� /$7& W ,2 9 -l.,
n T ors 9iwumoCCemdedWellCoatnetor - Daro
6.Is(are)tbewelt(s) Petma ant or❑ � .rr
By signing dds form.1 hereby aem}y that the meff(s)tors(;,ere)caaraunerI if accordance
7.Is Ibis a repair toauesstingwell: OYes ors �oX=02C. 00or154NCi�2ellConnruenoa Mania*mdthaia
• littlish l°rebooedtconureeuanatfamarim deplatnrhe Woe Oda � f b00
reeirundera2J,u arbMtcnon wonrhe baekVLISfam, diagram or additional well details:
S.For GeoprobelDPT or Closed-Loop Geothermal Wells having the ammo You may use the back of this page to provide additional mall cite details Or well
construction,only!OWIbonded.Indicate TOTAI,NUMBl1Roften! cotlstnlcltondetails.You may also eltechadditional pages ifnecessary.
drilled: ,SRRMrITAL IMSTRU l -
9.Total well depth below land surface: k X (h) 2ea.For All Wells: Submit this Iota%;Orin 30 days of completion of wall -
: Perm:00w*boa cholRVlma,r(esvmpri.4200'am:41M muuttucttonto the following
10.Static water lever helear top oteasiegi (IL) Division of Water Resources.Information Processing Unit,
ffwarerlevel le abase ayes we+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. la 941 (In.) 246.For infection Welts: N addition to sending dm fimnin the address in 2An
` Q r . above,also submit one copy of this foot within 30 days of completion of well
12.Well consltnNion method: I�t1 constmedonto the following:
(ia mgc,rota y.table,tract pull;eta) -
Division otWater Resoarcet,Underground injeenon Control Program,
- : - RA WATER SUPPLY WELLS ONLY: 1636 Mats Service Centel.,Rakich,NC 27699-1636
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13a.Yield(Epm) -•0 Method of telC e�lr�r44. ile.For Water Senuly&Infection Weller in addition to sending the tom to
the addresses)above,aim submit one copy of this form within 30 days of
13h.Disinfection type: Ft Amour. CV.I completion of well construction to the county health department of the county
where conshueted.
FotmG►-1 WM CatodunDepanmaatofEavuoraainwi Quality-llvlrionof Wow Resources Ravited2-222016
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