GW1-2021-00404_Well Construction - GW1_20211230

+,LL COIYSTKt,)00 no=f raw-11) or ntarna use only!
1.Well Contractor information:
t3 si[d G. CannedY
Woil controcior Nome
2126-A p
NC Woil Contractor ecAINmlon"w"ller
CannLd -Brothers Well DdHing, Inc. "Imm vim
Company Non
2.Well Construction Penult ff:. �GJ -v y L)
List all applicable Imil eanrintellon form a N.e,tlrr rnann"Soak,i'ariance.etc.) R R In i
3.Well Use(chalk well use):
fN!
uultuml SMunfo' Ablio jv R,
hennal(HoatfnglCooting Supply) pal Water Supply(single)
strleVCommemini DResidential Water Supply(shared)
WORD
Ater u y c:l: _� — - __ 1t, v A.-ln el
ftr Recharge �drottndwater Rcmcdiatfonfer Stomgo and Ra every9ullnity HarrierlferTesi Dslolmwalar Dmitmgc Z d n- 3 i ! 6rimental Technology Daubaidortee controlhormal(Closed Loop)c 1 Head in RotumR- Ozmlalg under L1 ItMeW j p, ft., (i,Qm9
Date p welt(a)Completed, J 2 wall tna 12 tl.
$a.Well Locatfonl ;LA. 3<v A.
., /n n. n.
FaraiityfOwmi Na* — Pac{ti+y IDk(if appltceblol R; R• j. _. ___
len] 144AAA Am P.
Physical Addmos.City,and Zip VT n. tt. --
Imams
County Panel morlil"m an Nor.(PiN)
6b,Latitude And longitude in degmWitntnoteslascov+ls er dedalat degrees:
I If woll UK one IaUlong is suliiolemq IL comfltHon: r 1M
` ��— rarlstune o racier txv+c
that i�- -- - —
--—— —.---- 0y swag tRk,fDrtm,l h cad Wirtflhl uses Petrol corrmucttd in occdtdanm
7,Is this a repair to on aidsHttg wait 13Yvs or ' WO/dA NCAC 01C.Of 00 or f!A NCAC 02C AI00 Well Censtnrrdou Standarrb and tha:a
�Jthls(s o npatr,Jl it out kr►ogtr++ell cenunretion tr}Jbrnrmtoa and rrrpiatn rite nartrro aJlhe oW of this rmrd has b mn prmt'drd to da++vil ovvw.
repair unrlar 011 renjoAs seclinn or on tho hock Qrlhtrfa m.
23,6tta digrtlta or atdditianaf well details:
g.For Gooprobe/DPT or Clasadd obp Geothem air Weiis haft the samo You may us*the back of this pogo to pmvido additional well silo details of well
eonstmotion,only I OW-1 Is nardod, Indicate TOTAL NUMBER of wells oenatructlon details. You mayalm attach addiional pages Ifnom ary.
drilled:
R.Total well depth below land suetm: 3 (ft:) 24C Vhr AU ml Submit this fbrn within 30 days of completion of well
Nor 1n11ht)k UC)Lr liJl all drp:ks tralo m"for"We-3(tttlfAl'anA oomajittion to 1following:
10,Static water level below top of caslagi a (ft,) Dlvlatmn of Water Rea uro'm Infortluttton Pr wwhv Unit,
f luster►e+al is abo+a mi1q,arc"+" 1617 Mali&Wee Center,VA101 ,NC 27MIS17
11.Borehole diamoter: �31L (I a.) 24b,�kp, ►k add t in hio it
u to wAN the form to the add=in 24a
12.Wolf conttrnatlon metttodt Rota above,else submit one copy of this fbrm within 30 days of completion or well
p.o.auugar.rotary,cable,direct push.etc.) eont:fnlotien to the tDilowing:
oiv1s10n of Water PAmu ceit,U0iderlmitid Iglefto Control PrWam,
FOR WATER SUPPLY WELLS ONLY: nn tats Mail Service Center,Raleo,NC 27MI636
tan,Yldd(gpm) v Motlmd of lest: !y��� W For vim Rink k InItAll' Wetin In addition to sonding the form to
�., p � the address(m) above, also submh,one copy of this Ibrm within 30 days of
13b,bisinflection type:S,7i "*" Amount:_r,....��,' t..�.. eomplation of wall cxntsiruc Lion to tlao'county Imith d9mnment of the county
whine consuveted, I
TH
Font:OW-1 North Carolina Doptu moni of Etwk nilmial Quality Division of Wmrr RcWutfas Rariwd 7-a1-3016