GW1-2021-06860_Well Construction - GW1_20210429

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WELY.CS»1 IICTFON RECORD(GW 1) ® For)ntemal Use only: k
t• I cAintraonr Information: I
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tVcll Cmnracior Name 0, L" T To °ES MN
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lndusirial/Commereial 13Residemial Water Supply(shrew) iR GROt"
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Physi tl Add cx,City and Zip IL A.
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Couneyn••1�yFFF Parcoi rdcmtfntion No.fPIM
5b.Latitude nod Imtplitode in elcgreedmimttes/seconds or decimal degrees:
ti%VOI field,one lattiong is, •e acAtinn:
6.Wave)the welt(s)dPcrmnneat or DTrorporary Signature oreedefimtweticantractor Date
1;v e/pT&M arGe-(orm, r hearAr tavrif}:that the n¢tl(r)ww(were)eartretnwfed ftoewrdemv,
I Is this A repair to an existing wrJ1 Oyes or RNo adth/S I.SFr'p4 02C..0100 or 15A NCAC•02C..0200 Well Comfenrtion Slamhrdl rmd that rr
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IL Site diagram or additioml well details:
A-For GeoprohempT or Closed-Lnnp Geothermal Wells having the same You may use the tack of this page to provide additional well rile damils or well
unnvtructicn,nnlg I GW 1 is necded. 1'ndicato IVfAL NUMBER(jf,%riis v)n9tructinn details. You may alse attach addi(ional pages If ntxxsstuy.
drilled:
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9.Total wclideptb below land surface-. �,.� �� (R,) 2,h, e'er All Submit this form Within 30 days of complexion of well
J nr mad/it.lr+rrlle/:stafld�rrlt�ifdJ�er tat(exdmnk-1 g 7U(I'mtd 1�}01fF07 comic Lion to the faUo►ilig:
I U.Rtptie water levti betow top of easing: _ (ft.) Division of Water Resuurcts;ltafor ration Processing Unit,
1Cn'ndu fasvr!LT i+hivi!offing.I�raC 1417 Mal Sere Center,R*ldgir.T4CZ709-16t7
i i,llotrhoirdiametct: UG e �c��(i�n/)�y �� 2•ItL For injection Wells: Li addition to sending the ions to die addtess in?Aa
l2.Weli cnastrsedon Inethad: Vl lhf 1 strove,also submit one copy of this form within 30 days of completion,of well
omstruction to the following
0c,Olga:,mtarp,cable,diced Push,cte.)
Dlviston of W ater Rrawro R,Undt rgreand injection Control Program,
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OR WATER f+I PPT V (WELI—S ONLY: 1636 Mail Service Ccatw,Ratclgh.NC 271rh9.1636
Virld(gpm) ` iltetheul of lest: 2:tc 1tr WitterSnnels&ioloetiongalls fnaddidanInsandatgthelbrmmthe nddicss(es) above, Also submit onci copy of this form within 30 days of
3A.Disinfection type; Amount: ctaplction of well conwuction to the connty health department of the county
whom conarmerea. �
I/1mrrCilN-1 Worth Owlinn Department offta.•IrtinmentalQaatity-DivisinnotwmerRaOuTr s iReviaeA2-222ai6