GW1-2022-03190_Well Construction - GW1_20220307

• or Intamil Use y!
1.1Yotl Contractor iniartuatlont
Rangy d 9,9annfidy
Woll Cantmoto,Norco R. '
2128-A
NC Wort Commoner eettinwim Vrnmber
CennadX Brothers Well CNIUng, Inc.
Company 1Vema L&
s 2.Well Conslroden Permit 0: a)C ;t' ` Ov D/�q
Wt all imli able tmll consmrction soar ur r/.e, ono%Bate, wlanm etc.)
3.Well Uo(cheek wall ace),
oter 1 u pply W'"D I I s
Agricultural &Ctatiall
�ublia �D tt, �� n, .� im d,s- �,yJ v0°
Qanhormal(Hasting/CootingSapply) Wotorsw*(single) ft. n1 to
lndutnriaUCommorciol DRosidonttal Wolof Supply(shared)
ILO
Non- ator Supply W4.41, j) R. pro,%
MOnitoriRcenve R, rt.
eMM wall:
R. n.
Aqulfor Reohorge [30taundwolor Rcntedituion
Agulrbr Stomge and Recovery Salinity Harrier It
Aquifer Test C)stormwda)3roblagc ft- *a % ro
Bxporimunlal Technology C)Subsidance Comml R, R.
Ucothennal(Closed Loop) DTraear
pooch a{(UMIngCoolipA Rate lain u or a I Rama e
Q 3
4.Date Wett(s)Completed. l 11w d R.
So.Well Locations 3 a f y R' Yy) /x
Foollity/0%Mer Name PulMy ION ftfappikoble) tt. R.
L
Phyarcal AdEroa.City,and zip Y P-
S ! it) t � su9 �di
Cuunty I'lo of Wentiltatiaa No.(PIN)
6b.Latitude and longitude in dellreasindnutWeocooth or dectroat degrees: M
AR 0
(irwallnolo,ono iat)jon is out cant) 7 3 U.C7ertlticetioas
6' b N t ` ( w a�
G.istnt'e)me well(0)MA/M attt t or C't'omporory signstuic orcolnod waitontloot Hate
►$'i nit fA(r n,l Ae++e ,eat Ihtu tqa imfl a) hmm)mimwted In arcordame
7.Is this a repair to an oilitting wellt Dyes or u1(h 7$"AftCa?*' ,alga or lit Ncw o2C.om Wetr cbmtnuvroH tsanaarda and that n
Ulhlt It n rrpolr,�111 ant lvtoutit Hell toturrtrdlat Irttbmtallon cad raplaln iba natts�e Nrha coM'yth/:record he bran prmldad to rhr brll omwar.
repair m�drr NJt roniard►+rNtnn sir entheback q/thtrjotm. py,$lie� nJ or additional well detaR>rt
8,For GooprotielDPT or aotah4l aop Coolbermat Wo s MMYW the some Yet'n�'lust lice took or this page to provide additional well silo dotni)s or wall
consintotion,only i OW-1 Is heeded. Indicate IDTAL NUMBER of wells construction details. You may else autich additional psg�if tsaaassory.
drilled: wwmm
9.Total well depth below land surbeet () ,�,,,,.,;,(tt:) tea, .� t Submit this Ibtm within 30 days of completion of woil
Nnr M1111wr ual/.,list all depth.,Udomat ratamrl IMl' ►am► M9011 yoti0n Onto allowing:
10.Statle water level helm top of ettsingl �v i�) Dift"of Water Rmuroa,ipfatuaftri Promsing Unit.
(/umer towl/r abate o4q,ttir +" 1617 Mail SoMea Center,Ratsigh,NC 37699.1617
11.Borehole diameters ,.... --on.) 24b.JUMDOLS&I in witioIn to wjwg the Form to the Wren In 244
Rotary obovo,stsa submit ono copy of this form within 30 days or winpiction or wait
IlL Wel(mast tttttatberne dt Ro.nary ..�,v,r..., ortnstrustion to the('41towing:
(Le.sayer,rotary.cable,41MA push,eta.)
D1vhltrn of Water Resolorew.Un lergmadd Irl{eedon Colt"d Progrstta,
FOR WATER SUPPLY WELLS ONLY: l t'A6 Mail 8ervtoe Center,l3atelgh.NC 2769 I06
E
130.Yistd(gpm) ��—3�., Method of test: W t to addition to sending the fbnn to
"Rua wdross(cs) above, also submit ;ono copy of this IiImn within 30 days of
13b.Disinfection typo: Araeuntt D P omnpWIN of well construetion to tho courtly health daporimen►of the county
where emttucted.
7 l-1
Fort OW) North Usrolino Dopenmatt►of @nvirolnenill Qusiily•Division or IMM"ltu:soutr:as Revised S•al-3oIG