GW1-2021-03568_Well Construction - GW1_20210823

i eb 1519 06;43p 019arwaterUVeli Drilling 828-622-7241 P"1
AUAL� ION ItEco Glw lil., Fnr intarrmi Use nly:
1•W Ifinntraelnr infore�atlon: _
,l�f� WI
zort>rs
ell rollw&lor Name " ro
tR
VC
W�UI�Cnnnapott tlfieaHon Nutnlex 6, R C 11t1i+ tar OR
I 11( 9 n ` p/ TTO �L7li
�a { �l !r. '+lr ,i in, UC
Company Nnme
6. R C t]B AN'tatgat
Z.Well Co"W"lion Permit W. ath—SIMMhA L
i,txM ON W+plicabla+veil crntraltmlenp Mft.V t%+t r/!C C.ormw male.Varlancq etc) H '
3.�Yrll 111e(cAoc&Well 0se)-. sr.
U�InduasiriallrcAmmcrciaj
ply lAL
io,'W(1.108 ing/Conling supply) Residential Water Supply(single) . in
DResidemfal Watersupply(shared) To MIMS
Non VI rater s fl !1 d
ttpplY Vl'all_
x4tmito Recovery
tn�letlOn tt.
AquiferReellar6c 13froundwateritcmediatilm A 8 fUtSiGRAV6LPA o
AquifcrStorspo04 tccovcr.y DSalinityBnmier K E.
is LA zt+rerr,00
AquiferTcst E)SttumwetaDrainagc tt IL
Experimental Tegimlogy [3Subsitiencc control ie a•
Gewthcrmal(Closed Lnwp) 13TOWU 11j[, 1.OGEd
O wthMnnl Kcadn oatin Retzlml dthcr am tmdor 1121 Remarks) T (�
�.n,lew�uR)c��►,�r�>t:�._?-�� w�u Ana___�._____ L rr, . a. �
';"-Well Lacet,nn- De-1 1 ec Job L Lk
I.acilit3:'1h+arer acne , Faml"tytoil(ifapplicalrlr.) n' R• [� '�
Ph leaf Addrr}su, ft. R v
City,and zip
S
Cmulty ! �t pareal ydmii-icatipn No,(1)"
.ril>.t.gtltnde atrl Mngptutk in deg(saes/minuoestsecortdsorrlccimal rirgreas: --•
(ii wa11 fierc td,one ratrMnn in qufiicicnt) tt~a tinn:
6.IE(are)the Neu(8)MPl4 .ft t ar aremporary SipoNrvc oFCkrotvVdlCaatraator D1ae
liv ellm/ag 01N.Fora; flip mWx)rmc A mW mr nWad in—rdmrce
i.Is Qlis a rcpalr to an existlag walk oves or Mo watr iSf bC'dC 02C 4100 or lSA NQV..01t:.P.200 WeNCamonrAw Slaorlards mpt Am.r
Mrll..ix:srgjd'r.,nllawkimwnTMOR0on9rs+dlani i+rnalimrmrdrspJoinOle.nnmJI!Of1ho o4v ofilds rl.wd Im am pm► *dmft,sodlawser.
r+mtr rradr r eel/MMal o srxryat spas 1/0:hunt nflliis,tarn+• 2,3.Sitc dkjtram or additlemal wdI de t1b,
R.For Geoproheit►fi+Tor owed-leap Geothernmi Wc1hr having lhaamn- )foil m age ay use the(sock of this p to provide adifida ull voM site damils or well
Ixtnamlctian,onh i GW.I is x1ceded. tndioaro TOTAL 14UMBER orwOls cjMgv Linn,labile• You mAy also Mach addllitmel pgn ifneeesrery.
drilled: _.. � Ai•1Ni'gtr[T[A1V$
9.7rntal walitrepth below land surlllcc:,,. __( i � . 1�r an wNlo: Submit trio form within 30 dabs of completion of well
!nr Mltalpfe N rllctit,-IMd wlrr ifefferrnr(cramp/-31h?tU+b 11@101►j congMMiwn to the 1111111neing'
In.Static water level beltnr top of taring.- ___r_____(ft) Divirioa o f Water Resuulm s,lathrmmflon Processing Volt.
i(nrolr.rAMI Ma rohlve cmfng•fee"•i, 1617 Mail Service Center,ft1dgh.NC27 t4"-1617
ti.lrotrholedJamrter: zqh.Rw s.tec_ n� •omits; In adtlltion�to sanding the,brut to Ott adkow in 24n
c above,arm liubmil one copy of this f n-(tiro 30 days of rmmpltdlon of well
►z Well cimttractlam methM.- �-� olmstinlaitm to the folkntliing:
(i c,P-Wr,-Mr.mbk,10ro t pt155,ti7c.l
i>"lon ofWaftr Rtamlt cat,Unda`rground Injettlon Condvl Program,
[13
RWATER R[.M N WELLfi MLY: Irr36 Maa sorVioe cc�,ltalcl0.NC 2T6h9.3636
a.Yield lfiptnl lYlMhot!of tesh tic FtrWQterSGnniv&ttiaellnn'W�Nh isnddMan to minding tht form mthe Fill t'ess(cs) above, also submit one copy of this farm Witi in 30 days nF
A.13Isfrrfectfon type: Amount: comnlctfon of%gall corm xdon to the;calmly health depamaqu of the manty
v4mrc�1Wtf111.RlQ. f
it
I+oml GW-! i orrh OVolinn Mpnnmont of tin0rdnavinral QW 11y-Olvia+mt ceVlaer Rosanmac RevineR2.-22 2at 0

r'endq iospe_c,rior)
l