GW1-2021-04017_Well Construction - GW1_20210823

828-622-7241 p.1
F els 1519 05,Ap Giearwater Well Drilling
W LTL CONSTRUCTION gECURiII 9W-11 I nr Intcrrtni Use Only:
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3.well Ilse(check well list): I7.S=3141
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t Mothcn_l(19eetinlyCool'mg Supply) Meidential Water Supply(singic) R f+ to
lndustriallCommereia) Residential water Supply(sbated) 1S:CR01f[ ro tee i ttM D&AMOUNT
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Nnrt li nstr Supply Well: its fc.
A1aeitoring Recovery
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Aquifer itecharpc [3oroundwoter Rcmcdiatian 19 SA(Vt)1GltAVBL PACK to hfe
SalinityBntrier FROM TO MA t L 14VilGACCNIINTMITHOD
Aquifer Storage told Recovery 13• -- n,
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it<perimetttal Tcelutalogy
5umidenee Control
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cauntY Pareel ydctnifteation No.(Pus)
51t.Latitude and longitude indcgreWgWmite..s/secondsordccimnl degrees;
(mil well fieltl one lat�onp in soft',wit) (�c v t i I► 12.Cet till an:�— Lf-30
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(i.1S(are)the,y!!1(s) Pcrmenent or ©ITemi►nt'n*v
By.or No g rim rhA,»,!hrwhv amrily that tGr.+wJ1{.)nrrr hrarnJ cueerrtterrd at aeunrda rcr
7.1+this w repair to wn ctciyti ag wcSl: Yes � a tr A tit:'AC 02C_#f lr0 nr 1SA i W--4C 02C.'d110D Wee Cr rtrlmrnnn StanrlerAr mnl Arm.r
lrrl,te;,n repair,ill awutnnwn ww4r.:acuruurnn irrjmmarim�Duel uplafn wMc Oolun•�fcFu c+�RY nf!ltfr r�xnrd has htCn pr»lddwlf r0 rbc wolf n1vtW.
n;xur under t.21 rcmajiltr mctran ar na die hark of fts rbrm. 1.�Site dhtgrxm or tidditiotmf well deftib-
Yra may use Cite bm:k of this page to provide additional well site dcWh ar Well
8.For Geoprabe/illiff or Closed-Lang Geatthcrmal Well"bav'ng the mitre Gtinstmrlion details. You may also Mull additional pages if necessary.
txntmmction,cmiy 1 GW1 is needed. rndiceac TOTAL NUMBER or-11S
drilied:
9.Toot welt depth below fund surface. ` (R•) 2.1n. fsor AI! llLeils: Submit this form witl in 30 days of romplation of%veil
l.nr nudNprc write fits nlidcpgce jA�amiu pmuple-3@jow and'@ Igol construction to the folloMn6:
10.Static water level blow tap of aging: tL/C) 00 Dividoo of Water Rnuurcm.lnthrmatfon Proeming Unit,
10.Strflewanrvwuaclbeloins,ucc"• • iJ 1617 Mal gcr*&ce Center,lt9fefgI6NC27d"_Ifi17
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ti_Rart3toledtameter: "` (in."} 211h.Tvrr Iwicw:tion Wdlx Ta aMtion',to sending the form tD du;address in 24a
�n 1, ,( akovc,also Submit one copy of this fo►m--thin 30 days of comple lon of well
Iz.Well construction method: l L'� '( a►ttsttU ion to the following
(ic.nngc,mMry.table,OwA posit,sic,) Division ofWater Rt=rm%Underground tnjectioa Control Program,
ibR WATER f+t FPLV WELLS ONLY: �A 1636 Man Service Ccnte',RAWO,NC 2709-1636
to Aiethno or test: Y` T—� 24c� Rnr hcatar Su my&iniaeflon Wells In addition to sunding the form to
IJa.Yield
(gA 1 the addross(cs) stbova,also submu.one copy of this fomt wiliths 30 days aF
t3b.1?isinfcctian _ Amount wmplotfon of well construction to the'COMW ht:9ltb dapmtrmnt of the rxmntY
type where corwttucted.
I�nmt GW-t North Gfimtimt Deparrmonref Iinvlydnmimml Qnnlity-Division of voter Ravonrcaa
Revieed2 22 2b16