GW1--06645_Well Construction - GW1_20231006

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• weJleoatraetotName FROM TO DESCRIP17ow`- -
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2.Well Construction Permitti: 7C/ 7 FROM TO MOWER i 7TRCi0 9 MATERIAL
Lftrdl opp$ea(tie waif eautntedonpermin tie.UWC.Cowry,Scare.Variance,erc.)- tr. tr. Ia
3.Well Use(check MU use):. R. h. In.
Water Supply Well:
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FROM TO DIAMETER SLOTSl2£ TRIMNESS MATERIAL
b Agricultural - ,Q.,MMwicipal/Public 0 n, re to.
mil Geothermal(Heating/Cooling Supply) esidential Water Supply(single) rt. m re,
MIIndustriat/Cammercial DResidential WW1 Supply(shared) — .
—Irrigation FROM TO MATERIAL LVPIACEM ENT METHOD&AMOUNP
Noa.Waler Supply Well: O d It. r ilie .
Al Monitoring DRecavery 0. R.Injection Well: _
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• !I Aquifer Recharge DGroundweterRemediation .
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■Aquifer Storage and Recovery DSatinityBonier FROM TO MATERIAL EMPLACEMENT unstop
- - MI Aquifer Test rf Stormwater Drainage ft. tr. .
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1*Experimental Technology DSubsidenceControl rt. ft. •
• 1t Geothermal(Closed Leop).• 0Tracer alkDRIEIIIROLpC(iif ehaddlriouniihielaii'u&iii _
_Geathermdl(Heating/CooliiigRenurt) 0 Other(exQlain under#21Remarks) oM To ursCnlvrinNSwtcr,Rattans.sotvmck_Dp.enatiue.CIO
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4.Date Wells)Completed/0- d Well IDll, bra h 8rf ff. ei/a,,,JT'e-
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Physical Addrmt,City,and Zip IL R. .
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County Parcel ldemifiatiae No.(PIN) -
Sb.Latitude and longitude in degreea/mtautalseconds or decimal degrees:
Often Bald.nnalarlomtgissufficient) 22.Certification: ,44,, g a- 'a
&e..ti-- Adievi /a-y_.?.
6.Is(are)the well(s) Permanent or Temporary gi�+t jrc oe a ified Well Contract.; Date
By eigning this form,I hereby eery.&thin the ireli(r)war(were)emutivcted at accordance
e 7.IS this a repair to an existing well: DYe' or �}No with is,1 MAC 02C.0100 or ISA NC.0 MC.0200 Well Conrtnrcrion&adonis and'ihat a
If this isarepaf,Jillotaleanswdrcontra:cram*formationandeaplaMthenaaraafore copyofrhu"mod has Daenprortdedro Mewl,owner.
repair wider121 remnrla radian or on the bae4ofthrrform .
23.Site diagram or additional well details: •
• 8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
eonstruction,only 1GWlisneeded.Indicate TOTAL.NUMBER dwells construction details.You may also attach additional pages if necessary.
drilled:
.SUAMII TAL INSTRUC1'IOS --
9.Total well depth below land surfacer -57?,5" (ft.) 20. For All Wells: Submit this form within 30 days of completion of well
Formeteple wet forerldepth:fiepenny(erateple.30200'ond4160•) consnuetionto the following: •
10.Static water levct below top of casing: .S (Cr-) Division of Water Resources. Processiu Unit,Ifwarerlewd tr above ming,we+- g k
1617 Mail Service Center,Raleigh,NC 27699-1617 •
11,Borehole diameter. 49 1/4/ On.)
n 24b.For Infection Weitet in addition to sending the fmmao the address in 24a
12.Well construction method: 1\O r yt - above,also submit one copy of this fbon within 30 days of completion of well
(i.e.sugar,rotary.cable,dueei push.co.) construction to the following:
FOR WATER SUPPLY WELLS t ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) Method of test 3r . l Ile.For Water Sunnly&Infection Wells: In addition to sending the form to
type i�f f!� the address(es)above, also submit one copy of this form within 30 days of
13b.Disinfection �1 Amount. _ C��s completion of well construction to the corn ty health department of the county
where eonsnucted.
FomaGw-1 Ranh Quail=Department nrEnviren neamlQualiry-Divisional Wow Resources nevised2-22-2016-