GW1--06753_Well Construction - GW1_20231023

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WELL CON TR1YCTIQN B ECQOD Far]ulnae!Use ONLY:
Mb form tanbeused liar single orrnnkipie well. ,
I..Well Contractor Information: `
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ivellteatt>a9vrNstm �,Ip ti to rn ii: � iNC ..W
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Comm Name . SPROM AkSIN+C�OR ' wO 1 1Cs •. .., �1' ,v
1 Well Construction Permit ti: (4' �9 1 3 Li D - ors „ .�: ... `THIS SS ' A7AiERDIL
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.. hind cpikable weiperralte(La Can*SON,Yarrancce.inJecu*etoj •
fit. ft.
3.Well Use(eberltweli crew): •_17: 16R__-- ---- —. ... ' •
I Water Supply Well: I risola � iiiier>nz waryeyes_'mac . �,
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' OOeothermal(Heating/Cooling Supply) liatesidential Water Supply(single) • it. ra. i ta.1. . -s I •
Ll1ndustria1/Co rnnercial CIResiderttiel Water Supply(shared) la-": :`t'
DIrrigation .:t3Matr TOMATERIAL .as
Non-Water Wen: _ 0Z.D b fOI ,q a d
CQMonitming • ClRecovery rt. - ft; v •
tieettom'Giteli: •
ClAgutlaRecharge 4CinmmdwaterRem:di ion 'x9:' ViltiFaeg i>R li1e)• :.:...__.__ ,
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ClSxperi ental Technology 17Subaidence Control R I - .
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❑Geothermal(Closed Loop) CiTt'acer FROM TO itotar bmenesaealihoahyne,=Iamb,eta t
!Me thermal(Heatineenling Return) DOther(explain underd21 Rom) 0 R C 10 •
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Date Well(s)Completed: Well ION ...._ At_ ee e7^Lg. I m ... 5e a A�
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Sm�WellL9cat�n: ti. E7V nu r eR.eil re t•vv^
Il iOwnerName Faellity MIA(if available) = • m�
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P6ysialAddreaiti'LSry.end Zip ! S .r.. .. .,�
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Canny Peal1detaiecadonNo.(PIN) ,
Sb.Ladlede and Longitude in degrees/minutes/neonda or decimal degrees: 22.r`c.HRwnNnn• .
Si of CertifiedWcltCoakacter Ds+
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6.Is(ore)the welds): permanent or 'C3Temporary Sy, 'figthis Ana]ley arta,that the ueal(e)war(were)construeled to aceweanee
wl 15AAiCAC 02C.0100 or lSA NCAC 02C.0200 WelConrmrctlla,Standards and,hat a
1.is Ibis a repair to an ettisdng well: -DVSs or fro •cif Otis revers 1has Ibsen provided m rho trell armor.
Ifzhi.e lea rersafr.ftllout lea we seellonsentettentqftrfitatlonandexplalar ►noneoar
,coral,tmhrii IAranktsvolon oron the back .'thlsfbr a 23.Site diagram or additional well retails:
- , You•may use the back of this page to provide additional.Well site details or well
s N.....r...an.a>*.ata.nnet eta fi• eoostrurtinn details. Yen may also attach additional pars If nec
Per mvLirir I...prim/I n..Av-IvMps nnnhr tec7e ON1Si Nrh AI omme.vw vewnrio/t: m , •
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Sti Totalwell depth below lend surface: (fw) 14a. Far A,tl wtdle: Submit this form within 30 days of completion of well
Per multiple wells list all deaths d j'eren,(ample-3 aO200'and 2®100') construction to the tbllowing:.
10.Sledcwater level below top of awing: AO (ft) nlrfsion afwaaerResow weer Information Proctuled>lF.a>,
(/'water l.vet is above casing,use' " - 1617 Mali Service Center,Raieigbr NC 2769,4617 •
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12.i oseitele tiinm¢ier: i.wj I .. ,.i —
'4 R .. J. i rr� Z4aabove,also submit a copy of this form within 30 days of completion of well
12 0/4 W.pY t14W14..apWYW ..r v .�..• ...w..w wig Mu.:,...
;aa 00;.::.ra.eo;,'.cy........r.w.e,:,:c) .s
of Wider Resources,tb'ntiergrotlinl itt ccuun Control Program,
F WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27ii94.16
13a.yield(wpm) '0 Method of test , 4 24e.For Water Suin ly&ltgeedou Welier .
Also submit one copy of this ibtm;within 30 days of completion of
man ape: k+ik , AmountZ. 16 well construction to the county health department of the county where
constructed
Form 041 . . - North Camliaatietartmeat of 8avitomaeat and Naomi Resa rcea—Division of Waterlesources RevisedAvoet 2013