GW1--01085_Well Construction - GW1_20240216

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Feb'151905;A•3p Olea,waterW®IIDrliting 628-822 7241 P.
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3.Writ Idle(cheek well use)
Water 5upp11'Wet!: u. . '17 fo . army arisaligill Tatm neon 1 nex itta4
II Agricultural •ManlclpnVPubllo U O. er. �'
tiA e • - (Ileatiag(ConlingSttpply) Residential Water Supply(singe) *r. In.,
I LndustriaiCoranietafat R,aidcntial Water Snppiy(sltarcit) }i ur - - • 1
Si trli_nla TO �vIVA6L $M�`:l
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*'Aquifer Recharge QAroundwatctRcmcdia!irm •f!<SA t/gLPAC, L. y,,..:., 1
11 •quiitr Stomp Arid Rummy °Sldiaityi)aaler p ,Ai fit .0'TI' I *"'r'.�`c
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*Experimental Tedmnlogy •f SubnideneoContmt O. R.
II Geothermal(Closed Loop) 7i:acer "1.11• 1.1 c•r LOC(.:: •.1:_:_ '_
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al acotttermatificltia$/Conlinalioni n plbm gexptarn undorii21 ttem uits) it. 'r l�ye0"k�ti�•r
1.Hato weiI(i)Completed: t"a,Q 'r;11 WcLl IAu 900 ( 2 01" ,r1 Ln l e' - __ ____
SR.Wen l rcostno: , I 01R (�0• v ft • e)ui Le
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Physical Adams,elmand rip - - 1
ilit(a ne.eq_ „:2-1,ampitsy Vireo!rdentifieationNo.(Pitd) M';• Cs,
St>.L*hfuda Roll jonglttitk in deglCeatloitrfueat9emndsm decimnl*gram t�- [tartan, , ' - . .(ir we`1 d,nee ieuraniastte l:lentd .� '
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thi,.lasarcpalrtoane:Trdtgwelh :Ycs or ONo lob 4 C.n26oTIP iCanuu ASt R Jhasa
f4daxrarcpall'allouthialniva mammal*hilbagalicn�andareatnth,:mum:(Om a'rYafllrfsrrrmdhacken mottledlollawellowner.
sraolnaler1121 nrmlaiceMgnn wart Ilia hAcArefthtsfonn. U.Sfite diagram or*ddinomdwalldt*llar
cn well
8.For Geoprobe/APT oD QkFed-Loop Geothermal Weliahaving thasame You NAY tree itrc ltafeT<01 dtis�Ia to 1�YWa taddlhollni well Oho sierra
tsmornetinn.anly I GW 1 is needed. Indicate TOTAL NUMBER°N cila t,p1g111tc3inDtirlttiis. Y4a�Y a o Mob adds t pages PFttoaelraary
drilled! r I ,
R?Mat wolf dept>t Mew land satikce: �105 (t) !for An%li SuAmie this Own within 30 days of completion of'writ
Far n imprevansudralitliptltttf(tffldrraa pea apse-setacr aarraeon?) {ilDyTIy{1pni(1111CIi1RSPfii:
In.Stolle water lovelbelow tap doming: D (f) Division otWoter Resmuea.Inibrat ion Preeesiit Unit,
if.gmrivvetlsalwivaeaftre Lac"." a 161171 1 antic*CentC/}:atI(C37699-sso
11.ltoit!itoTtdlsttiGtr r: �Q,I o (in.) zmte Fnrieleslion walla to addition'tothe lbw co Mie Wrings i in ton
Al Welt cementation mkt rc)far *rove.also submit one:copyrofthis form with i 30 days of comylrelat of' elt
tit.cage•,new.code,&set push.sta.1 ttNl9itadintetathc following:
DivdalonofVkaterReeou ces.UndentronodlinjectionCnan)Program.
MR WATER WPM(MILS 1G36 Man Serdeteciatar,Rolf dgt.NC276294636
t3a.Yield(gpml 3 ittetTtogef'last i—I 23e.liar Water Supply&i(tl[eetiglPWeik: 1 Iaddition wounding the tbmt to
- - urn oddress(es) above,also 5ubmitlano copy cr Lett Ron Within 30 days of
tab.i)isinreedmi eypet - - Amnon completion of well consuactton to t e county health department of the county
-- whore canau.emd.
NameQWt North CactinnOcentanco.alinulcdammtel Quality.Mauro of Water Rooms Revrvot2.22711r6

Wed MOW SIM-Stout Cardiki
Owner: New-Well:
4ddresaLC-V-C-X--
P2mit
I bgreby oerti*ftiarthe above rammed well was groused in appearance in with
all ComtyWeliraies.
tan Driller Rti Me000Uos siiputd3
cerdficate#: a A DatoGritatskl:P3
Construed= Grout
Total Depth: 0 S- ef-Maki-
TYPe:
CasingType: pv c„. Wetness: PrVII-f u,
Casing Deth: too Depthz_.(3i)
Diameter: C9'
Bight—
Drive Sloe:
GPM 3