GW1-2022-03769_Well Construction - GW1_20220404

1 o a ama ao y:
1.Well Contractor InMratatlont
Wall commotorrNam a 7 N• 3 �•
212e-A
NC Well Controptor CvrtiPbatba Tlamfror
Cannad Breathers Well DdIlIng, Inc.
f>.
CornitanyNoma (�
1.Wail C"ruedon Permtlt Ns 0 d v �
/.1s1 all appllrable HVII conslnrraon perm rs(i.e. nusr0,SYnM For-ti meet err.) p• p, n.
3.Well Use(chaek wall uem)t fl' R.
ater upp a r
JAtiuultuml [3Munfaloubiic Q° n, 3 n. a r- Im
ollimnal(Hoating►Cooling Supply) Dwidetstial Water Supply(single) - rt. h. Is
umdaXommemciol DReoldowtol Water Supply(shared)
Ater y e11 0• n, i e,2o Rrirooveo tulfer Recharge �Oraurtdaata Remedioilonul(br 8romgo attd ll0eovory �Sulin{ty>3arrieruiferTest DStomswoorDminago d a• 3 �B /ptuimontal 1•acttnology8ubsldoma Cantmi fl. A.
WIN I
othermal(Closed Loop) 'mace.'0th WWI cling Rotun @t or foutain under N s
4.Date Well(s)Completed. , j- "l-Woli IDN 0• D
so.Well Locations a Cart. a 7 p• f3''a 4
n. 3 ft.
Fnaility/t�wrtorNatne PaollbyWN(Ifumlimble) p' R•
Physical Addmw,Chy,alij Zip ;t 'y?q y
.a
nwewr.wrws ..,.uN .,9a..rwto j -7010
county marvel Mwillcstlen No.(PIN)
6b.Latitude and tongtlude In degttwirtinmmat/oeaoads or ttedtnal degreas. _ 4
(Ir woll field,use 14inoR,g is sufnc►ent) Nons
ij
m C:��
6.is(are)me welt(ss) sent-or �'i'ompornry nsturo 0 0 ontteetet �•.- _ _ .t�tc_ __- __.
✓s'i fitrrg iAfr +r,I her*cert(A.that if wdt$)fins Poore!rorummito in accordance
1.is this a repair to an oxistting Welly 13Yao of ulih 1!A NCAC OJC.O160 or tSA NCAC O1�'.0100.Yell tbiuurusv.on Siamfards and rha+a
$dhls is A rtpalr,/Ill oat Arr0ttn%W1 masin ellm Iip milloa ar atrpiMn Iht'rtaawe o/rhe ghlrk record has bent p 1ded to►hs imll omw.
mparr ardor n1/rontarb Amin"or an rM back gl'rhisform. 13.Site dlgmm or eddtdonat wall derAibi
I.For Gooprobe/DM'or Closed-Loop Geolli marl We o having the some You may use the back of this pogo to provide additional wall site doialb or wall
construction,only 1 OW-1 Is oecdod. indium TOTAL NUMBRR of wells construction detatis. You piny aim atttleh additional ragas if naoopary,
drilled:
9.Total well ddQp�pIh balmy land surracet IN 34a, t submit this ibrm within 30 days of catnplotion of well
ParmnitWo IIV-1 710I of/dopI/a Ld(pbrortr(aronrpfn. 1iN1' ( Ifl0') conmuat on t0 Ow fbilowins:
10.$tide seater level beww top of 011481, -M.) Divbbn of Water Rmurcell,larom"tton Proeaaltlp ashy.
(Yuyner lets►is ahote auhi y,ttrc"+" 1617 Mall SOM400 Couter,Raleigh,NC 17609.1417
i I.Borehole diameters. ,.►.y (lo.) 34ba tp LjAh j*Wy �t In additiiits to tending the fort to the addles In 24a
�iota�lry abova,also submit ono copy of title(brm within 30 days of completion of wall
IL Well caa ton tn tltrill V1A0ds . oonsirttstion io the fbllowing:
(I.e.art w,toloty.Cable,dirod path,eye.)
IDtVm"of Water Resources,Undeellronad injedloo Com*lProlmm,
FOR WATER SIMPLY WBLLS ONLY t 1636 Moll Bervlce Canter,Mato.,NC 27MI636
IJa.Vleld(rpm).. g,,,".,7.,.,,. Method or lost_-'�:G.G..`-r.......... t4c. act to addition to sanding the form to
"lttc v �� itsldrass( r oisa submit Iona copy of ibis (btm whbin 30 days of
13b.Disinfection typos Amauntt D Completion of well ctctwtruction to the county baaith dapanmont of the county
whore consumed,
Font OW-1 North(btatine Do mnent of snvhontnsnlq().silly•Division Of Wal¢r Rcmrm Ravi&W 2•22-2016