GW1-2022-03132_Well Construction - GW1_20220307

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M ELIL C0N5WC jLQN RECORD(Cf For lutemal Use(fitly:
1.Weil Cootr"tsr is/formation:
Wall Cotnractor.Nants
1!ROM TO DESCRIPTit)It
fL ft.
IL % --
NC Well Coate ttr Caetif cUm Number
tt ft, f la
Coady Naam
2-Well Coretrsctlon Pit M reg-11 � PROBE To DtAAtET6R 1 S MATQWW,
List aB ypptkubk sell ranarnrertaf psn�nita(lee. C,County,Slats.Vanr4mm ek) tt. la
3.Well Uee(cheek well on):
Weber S Wall:
PROM TO D'IANWIR ,sWTRita Twlr 1HA'IElafA1.
��'cd� �Mumcipai/Wblic ft. ft [a
(HeatiaB/Conlwg Supply) Residential Water Supply(single) ft. !�
lnebtatrial/C.ammaeial Residential Water Supply(shared) -
FROM TO MA M1d7 B®Yf @ Ad3otSN1
Nos-Wn"Supply Well: R. R.
Mom
Reccovery ft. 11. -
�Llr»omdwater Retnediasi� fL R �~
Aquifer Storage and Recovery Dselinity harrier mom To nfA1$R[At xaat ecat►i�ta t iofsrlfoa
Aquifer Teel DS%o mwaW Drainage R• tL
ExpessraenbtlTechnokoU DSt>mdenceControl if ft.
Gem"znal(Closed loop) DTMM. - -
eatin oolin Retain} nmer lain under#21 Remarks PffnAt TO R� Sa *� r rodttVeoth sts
ft. ft.
4.Date W edtsD� WiIE Iilbtl'
Sa.Won i'lociias tt.
X- ft. R.
Faet}ltylOwaer Name Facility ID#(if applicable)
Phya rogta,Cuy,and Zip
C-2ty Paroel Identification No.
�') --
Sk Latitade and longUmde in depees/minutmIgecands or dedind d%raee:
(Ifwoll fret,=0 kviong is autsciam) ,,® 22.Certlllxatlen:
6 Ia(ara)the well(e Permanent or �Tetanporaryy :, S�mtur.of >�well Conowtor� "per
BY afgrft this form/hertby ca*,dwt the weW(a)um(inane)cos vwwd im aworumtce
7.h tlbla a repair to as etdeon-Nen: [3Y% or e with 15.t N(:AC 01C.0100 or 1SA NCA('81C.0100 Weil Cocuaudi0n b7aftdrods sad that a
Ifdds tt a r ratr,jtll oat bw"vwu come we ion tnjormarivn and eaplatn the nature of Ae ropy gfthk record has been provldaal to me xrll owna.
rOVIr avrder#11 rWMWb nsrtlon or on the haaF of dtts form.
Z:'I.Stet diri6ot or addidang stall de db--
S.For Geeprebe/DPT or Closed-Loop Geothermal Wells having the same YOU may use the back of this page to provide additional well site demils or well
conanuctioa,only 1 W-1 is mended. Indicate TOTAL NUMBER of wells e.rnsttuction details. You may also attach additionai pages if nere smy.
ddW:
J SUBM 7T JbImmu TiONS
tal 9.To well depth below lard surface:,
For nwltlpis-Ik All all depths V_diffinet(example-3g200'afw 2@lopt (ft) 24a. Per All Wells: Submit this form within 30 days of ;onpled. of.11
oonst ucd4n to the following:
it
W Stake water level below tap of maitsg: L' (R
1jtWaua lead la aba►+e ) Dhidon of Water Resources,Wormstion Procesaiag Umit,
caalrts•eue."+ 1617 MAD ISWvlse C�tar;.) ftk49 ;NC 27694-1617
11 Boer aloha dlanmster , (la)
b.For-Irindan WeIDs In ten to the form to the in 24s;
12.Wia osnsLrtietku ruefbd., `
abo
. _ . .. � arldrtt sending address
wr one a.trpy'of thus form within 30 days of corupletroa of well c
(to.`auger,rotary.c6k.direct pueb etc.) ve also aubtn t pdovnng:..
• coastrucuon to the i`' .
FOR W.A.=SUPPLY WELLg'ONLY: 1 idou of Water.Resoarces,l,®dregmud h4ectioo Control Program,.
i- 1636 Mail Swvice Center,RaleW4 NC 27694 1636
gCleld ) Metiwd of test: ! 24e For Water Stanoly&Ise dft wuL& III addntioa to sea ' g the fob eo':
- the eddeers(es) above,'ailso'siib>rut sue.copy of this foam within 30 days of'.134t.DLlafaebloa typo: Amount: completion:of well.00nsttuctcon tof the county bait department of the county
where coasuucted.
North Carolina Depathatnt of Envmantental Quality-Division of Water Reeouroes f. .
Retired 2-22.2016 -