GW1--06394_Well Construction - GW1_20241025

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NULL CONS1RUCI,'ION O RE( (Cif-11 - For InternalU.o Only: •
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1.Well Con cter•Ialn . nt :o
;e' '14.WATIR!Lana •
' . .Well Connotatio w MOM • 70'r.. ! DnC.Il7IO1I
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• tic Well cootr.otorC«deo tto<Ngm6R • _
15.OIrTSR CA81Nd(fir wield-used welt OR LIMB Of.. Ruble) S
13 ram :, s MOM ro DIMIl1ii Tt3raotin MATt:iIAL
New. " t< �
1.Well Gulnefior Rerodt if: 3 If.INNER CARING MINORING(iidia>.d deed tar)
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y 1 ' +hats TO:,/, DWHiIiIl issTsrww, •
Dea1pplicAlp wall coni/atetenpertfli(te.tif cow,.State,'oAwK• R,etr) 41 fe .'7i('ft 1 lie 7Ytice- ' .
. 3.Well Uwe(cheek well ice):. i1.j n• 1 R la
Water Supply Well: t1 17.8CR>Lilf.. ! !
mom 'To 1 ; DWHSrin eLoroars TwantW-. MAT=
'. • DAgdculbrd ' . • . . 'OMtmidp.lWPy6110. . R ' It. .. Ia
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.'• . 1]Oeol6etmd(Healing Coaling Supply) -_,ItillWaidontiol Water supply(Anglo) ft.. it1..'•
• htdt, Ortrial Commercleir - -= OReiMeoUal'W.lersupply"(anted) II.OROii!
Dhrigaliop OWdla>IOO�OOO OPD-. : Moord TO. 'MATERIAL.• NPR IACIIMI II on AAM
Nam-Wafer Supply Well: Dileou►ay. •
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.R. •Z. - n• Nec('r. M!-y c.;
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OMtiailoriag • y+
• .' • Injection Well: �Y 1 l Z ( it.�l
' • ' . OAqui[erRe nnp - ClOtW rdwaterm Reediakon ft.
OAquitbr Storage and Recovery , d9d A BAND!(iMV$L=AC:C(If.ellka�le) • . . •
inityporde( • riots Tor MATsiIAL • staucirmateirion
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- °Aquifer Teat' . . • . • •flltonnweter Dnln.go • ' . �, R-
'• Olixperimeutal Technology 1:19ubaldattoe Control It
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• t]Qeothetmd(Lined Loop) L. [pima( • ,! • 'lg.DRILLING LOO(attach additional snap Uncanny) • '
Healkig/CaullnjgRetun) : O0ther(caplahRmder021Remata) Moral TO1ii. Di1CRRi141YkeMr.i.d.cr,wiM1ecklirtiadaete.�c
00eothe id(
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.�t.D.te Well(a)Completed::. /' ' .1 Wen in. i : - ' . R fl.
-" , 5d.Well Minden: ' tt 11
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rr2ca5, s I IL ft<
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Fa�illhylOnnerNino VaddtfID/(uTP ). ,' .• n P , a UL f 2 ` CUZ4 • .
Z(.o :a 6orkt;,.•'ji 0'n,7 k Por j ' •i •
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•• 11.1tlMAR$Dif i.
' , Count} •' • . ' • PawlIdentificationNo.(P , �I 1 • .
' , • 56.La plude•.rd l..gltnile In depseWminitedaeconda srrdeelmal d . ea: •
• (If wall fiol4ke.l.Ybai 1 aal6elwl)
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. N g/' . C I a 5• • Zz Certification _
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. fi.Is(are)fia.�7eD(i) 1Perrtuert tin I l g � � CJ /0 ZZ •1
DTeeep.nry D /_ / Dal.
� .. / Y • Dry /
. . 7.Is fhla!a re Rlr b as'Wider'well: pin.'it.. Ni• '. . • 134 ring lc o 00 VellrA1 A 01C alit/.0200 Welt C��ekiShin dM,
.(/tileIsiripe:F.fpwekie.rw.IIcware.eipnWorn t/e,t ' iron!'• . SMiwetiendthN
•!epair eeedrr VI r..rwRs sestleic.r etifiiimt.of*Isla ,,itc the riusmr the 9/e►rk neecdh.e fiein�r.rlde/b the win nmrr, •
13.Sits'
B.For Ge. 1telD . ' • ' � diagram it addltforal well icing,: .'-
c•F tcttck ry or C7oaed-L,.p Ge.lhermal Wells having the , ,,a You may Rue`the,b.dt Of this page in prorido.dditiotul wall•on4ttctlen
�Y 1 OW 1 la modal. Lid.wb TOTAL NUMBIIR of toe (add'Sw Ovef'm RBnitirkn Box).Yw may alfo.tl.clt.ddttiond Pagel if•
nocrr
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drilled:' • , . .
• r� �I �1 24.SUBMITTAL INSTRUCT IONS ' .• 9.1`oiii well depth belit►land surfaces ' Y 1—•; .- ,
XnincrlHpht webs lint ell (It) 1 , .
i hrY c*at(iaawyh-30200'aid 29/0p) Submit Ihb GN i mithin 30 dap.f nett completion P pci the following: .
10.Statlewiterlevelbelontop.teaalrg: 11J 0 �0.) 1I.. For All WeYi: Ihl
{f.vterlrrelle.beiaoeel.R;rr.+� )uihimadonProaaaa' ( 1 form to°Mahon oC 1 stet Reroutcet (D'
ing Unh,1617 MSC,Ralel
f E +. g14 NC 17699-1617
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11. •Borehole diameter: 1d6.For Irlectlor lt1'dir.Copy to Witt;U
{In.) ;c • ndergtumd. lniedlon Centng
a+a rl� F Pawn.I636 MSC;Raleigh,NC 17ti99-llilti
• 11.Well enalneHn:method: • '
p e �aaNc4 dieel 'r)•
�� 1 .r .ter Si•
I'I and O ea Ge Geitherrud Relarn .
FOR WATER 81)PlLY 1VI cnualy natal" I• ,w_ county Xe1L:Copy!
LLS ONLY: ....cw va ma ty\dtele ttt [�
3 ^ 14d.For Water Welk rodndi r 100. 00 GPD:Copy to°Wit,
13n:Ylehl( rR) • t_. Melhad of hob ,y r P . i • Pun'. CCP
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