GW1-2021-07061_Well Construction - GW1_20211129

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I.Well Contractor inrormatlon:
joald G. d
Wall Gontrhaior Nemon 3 R.
2126-A st.
we Wall Convector Conli1adan Nttl im
Canna rcthsrs Well DHWngl Inc. fL ft. rts
company Noma
�.Wtdl t.,onateucNon Pattnit M: . i- G � • �•�l �v jD R. R�Liar Of applimW a hell caitsbucrlon perm is(i.e i17� omo%gait.t artance,etc.) a.
3.Well Use(check well use)t
afarSupply will,
Agrinuituml Muni Vpublio U tt. It. t, a. f y ®11Z „vr
0eothtr"W(Neat(n81Cooling Supply) 8ttemial Water Supply(einglo) p p, la
Indutarioycommemial DRaaldendol Water Supply(shared)
man-Water Supply 'td. tt • v II. &c,4A P vL✓�
Monitori Rtx:ov � II, ft
on Well.
Aquifer Recharge DQmundtvatcr Remedlation -
Aquifer Storage and Recovery 0841inity But-A r To
AquirerTesl �SttlrntwataBrninage aZv o' s rt' f �b "%-
Exporimontal Tochnology 13subsidanoe Comml i►. R,
Geothermal(Closed i.00p) Ideal
0�th i t f Ratum lain atr 1 b.
4.slate Wc4lis)Cottptteted: ,(j� o"off Wall IDO / 7 b. I y th W
So.Wall Locations �' 3 R'
Focility/C)wwName Irsol1hylD0(Irotytitanble)
....N A Yyu-n Q. ..c (U G tr. A
phyaknl Ad�eas.Chy,and 7_ip t�c.,+vy�,,. 3-a'7 ({ :i y A' F.
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Cuunly 11111wel Identification No.(PIN)
Ab.Lotitndo and lonjitede in dagroWm.1nutcalsewrA or dedmal dcgtroaa:
(irwall now,o a lavlons h sumolong at2.QerHtltall0tlt „J I" '�J 01,111
�5 b ,N a a i y� �-2 W a-P.� / -a )
d.ls(nre)Iflo well( ormananl or OTemperary Bata o n Well of cnaestar We
oi,alg�tlitit(Ass�,M.I Aemed.�'om the nttll(s)ma NMI emwnfflted►n aeomditnm
7.le this a repair loan oxlsdq wa11t 13Yins Or %IA S.4 NCAtr0aC.0100 or ISA NCAC 02C.0a00 Well Consirwiloo gandaids and(Aar rt
llh(i Is a rtpglr.Jt!/outkgtntlo mit t enunfroon ItIlbratolloa a �apiale 1 he riaprre oj�be......R 1 Q/iMs rn erd Asa 6tr+t pr+otVdad ro rAr�rll oarnr.
ropatr mifor N1t rsniarb Sevin"&on the bock oft�farM. —~U.Site diagram or adQttlontd well ttt:tnitat
8.For GooprobeMPT or Closad•Loop Geothermal Wells haulm the same You may use the back of this pop to provide additional well alto details or well
milruction,only I OW-1 is needed. indicate TOTAL NUMBER of wells consttuctlott dMits. You may also attach additional pagoe if neoestary.
drilled; ,
LUCtm
9.Total well depth lsrdoW land aurthee: s .._....;;C 4) 24a. gtgy t Submit this thrm within 30 days of completion of wall.
Nor ntulttplo uYNs lot a(i daptlAs Udipmm(s:rO a Win conitruef On fa t to ilowing:
10.Static water lovel below top of eaainsl (R.) Divie"of Witter paaovnv4 infomation Nrovetsing Unit,
alwater 101vt(s abottr Cost%site"+ 1617 MOO Serft Center,Raleigh,NC 27OW1617
11.Borehole dlametert �► t (la.) 24b.JALhggj t in addition,to wAing the fonn to the address its 14o
Otary nbovo,also submit one copy or this!(brm within 30 clays of completion Orwell
Ii.Well eonatrtlatton tttetbods .,..,...e....e,..„a.,.,-,.. uonetmWon to the tbltowing:
(i.o.auger,roioty,cable,dimi pwh,etc.)
.....,�„ WvRton of Water lksoar o,U dwgrortad lojotlen Control Program,
FOR WATER 9VF t.Y WZLL$0M Vl I&%Mali SeMee Cotner,16tolgh.NC 27M.1636
13M Yield(Rpm) �� Mauled of fast: � 1 14c. In addition to cendin$the form to
1hr ttddresa(c*) abova, also subtn c one copy or this farm within 30 days of
i3b.1)isinfeetloa types. Atrtourrit !)d p �D7vl compWi*n of well eanatruction to iha county henhh doponment of the county
where coniaucted.
form dW! North Uarolioa Depertinent of 8n0roninoolel Quaihy•D"ton or water tie)aurcca Naviwd 1-�]-a014