GW1-2021-06661_Well Construction - GW1_20211007

W&LL CONSTRUCTION E R.D aWV- � J For internal t1Se Only:
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J I j j FRo7bt TO DUMS
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Compatry NOM
2.Well Cocoa Permit#t;
_ VR M TO DLQWC tea nsrtasa MATCRUL
list ale gpJkabie KV cmwmactionpervnla(I.e.(4IG County.State.Yariaxa,- efc.) tb tL �
3.Well Use(ebeek weg use); ft. tt
Watwr Supply Wen: T. M
r�rQi)M TtT �R !ice MTd TBtClII�88 bLt2AT
8RSAG 1
�Municipai/Public n. R. 1 .
(HeatmglCooling supply) dtautial Water Supply(single) it L
DResidaxdal War r Supply( )
Lit
NO N Im MATOUA6. AMOdT:!1'!'
Noll-Water Sup*Well: tt -Ao!!. �q
Rowvery % f
bosefts • -
Aquifer Retd►arge Dtmnmdwater Renelietian
Aqur`fa storage and Recovery salinity Barrier FttCl:
Pam To KATZRIALrat�ctt.�rarr Metes
4quifier Test O stotmwater Drainage . t%
Exp wimeaW Twbnology DSubsidence Control n ft. _
(Closed LOOP) DT=m Lwaftab
Return) Dother lain uudve #21 Rematics
4.babe Well(s)Ct mpiletod:� We"lDA ft
_..
..s.:wall laaeaao�►:. :.. ._ ...
Feei6ty/Owner Nsme Facility MO(if applicable)
Plsyuoal A;dihsna.City anst Zsf+ ,.:., -_.•.., :,._ _S14
(Joatasj,. Paloe! No.(Plh�
i
5b.Latitude zed isagltuft In or dermal 4egreee:
(if welt GKld.am laOMW is sufacied) 22.ICertilkadon;
6.Ys(are)the mall($) m Ferma mt or 13Temporary SitputeUe of Certified tli on ar Date
6y sVbq tl+ts foyn I hereby crr�jy that�wett(a)x st! 1 ca satrs+ctad to araarrdta+te
7.Is thb a repair to so esleEag well. Dyes, Or io "h 15A NCAC 02C.OI00 ur ISA NCAC 02C.0200 W,11 Contowdon Stars.'ardt and that a
1!dear it a rerpeir,)?u Out knmµt•weld conrtrtwyton iq formation and explain the nature of the copy of thin record has been prtrvtded to the K rt!owrrsr
ram*trr&r*21 rztsarfa section or an the back of this,fom 23.Site dialas or au9dltltaaat weal d a:
8.For tgoprobeiDFT or Closed-Loop Geothermal Wells having the Same You may use the back of this page to provide additimW well site details or well
construction,only'I i is needed. Indicate TOTAL NUMBER of wells consbumion details. You rosy also attach additiotutsl pages if necessary:
drilled __�'�! ia4 SUBI 1 TALrtycl'ptt}
4,Total well dtp&below IwW surllace: �`�'} _
(ft.) Z4a. Far Rll Wells: Submit this farina wttwithin3U days of completion of well
eexklp! deAthslf�' angpte F @2, ._ fA he foll0 'a e.wedleLlatali (au 3'" 00'and2
cc+nattuctrcr>a wing:-
14.Stati�rratec Ct!eI bean►telp ot+xdug. f� ,(fL) DlvisDoa tsf Wffiter ISZeDBarCfe,Iratorrnrttloa+FroeelOg Volt, ..,...
(j rwsdar level to aDewr.carftig;wee: # i 1617 DWers+►ee S Center,Raklgh,l�9C 1T69A 161T
eryY>eteelinn 6brcAac'1n addition to sendi tho Ibm to the address to 24a
11.Sorelrule diatrseter._;_^. ..._...{ln.) 14'D within f
;..; abaY -alitu a Cary i Dorn wt C On O
submit on a thre f 30 da of ox O Ob wort
°;12 W�ao arctlea mstbid AtF3 � oonsttsution to the fullovnag
(i a augre rotary,tzbk..Oirea push.etc.)
dltvbitn of'Ot'mtex Respftrcas,:lJrmd+trgraand.lnjcettoa Contrail Frogratra, F ..
FIDE WATT MMYLY BtP161J S t21r31.Y; fl636 R9al!mice deter,lAaledgb.idC 2Tti9F�ldx6i
Aletbod of ft": 24C sr Wt1 r£ru 1v dt 1�le tJ1 14�YPP in addition ear sending the form w
13a Ylel+dl( ) / the adtdrese(es) shove. also submit Date copy of.this farm within 30 days of
13b.Dldbateetien type: Amount: ! Completion of well construction talthe cotxtp health depattment of the county
where OCWtr a.TA
Farm CiW-1 North Contains.Deparernont of Eavb"'A=Ud Quatity-Divivion of Water Reaxacea Roviwd 2 22.2016