GW1-2022-06835_Well Construction - GW1_20220715

nu CONg'�'>Rr1rU R�'tL'ORD((„W 11 For Internal se o is 'I„�,� .,�,
1.Well Contractor Woribation:
- t 16 G► �bf�G
Wei!Conuaetor Name 14.iN ER TANES
HBOM
Z. TO
NC Welt Commetor Cet ifloation Number
tar I'dlre8t.t}RLIHE$
tntoAt � Tffi MATEft1AL Compmw me �1 f. IL la.
2,Well Cantiructlon Permit#: 6 W 0 7$O-�p O 2 1& lrlt'I't181NG. dead t
List all applicable-mil conahudion permits#e.— FROM TO Con 2 DlAntET6R
+n Iffc. J:State,Parlance,etc.J It, it. to � tHA7'EprAi,
3.Well Use(check wee use): ft. tt. I ter.
Water Supply Welt: 17 SCREEN
d,,,� t
= +Cultural FItflM To
@RCdIII:=I:cr
Dian�r>±re st.orsrat: Tetctcretss tuax�rL
emiai EHeathwCootlag Supply) Supply g' rr. i I
IndusttiaUCommen+cial tip y(single) ft:
�Rosidtariial Water Supply(shared) IL
Itr1 lion ,
Non-Water Supply Well:Mon d C Wring ft'
tt.
R
n ecovery' ft. ft. B
Aquite!'Recharge
DtitvundvvaterRetnediadan ft'
Wfer Storage and Recovery 0Sauu4 Hornet 119.fiAND/G>ZAItEI.PACKIf weabld
Aquifer Test 13 RRoi}r To xt r�r
Stomtwater Drainage ft, � >:nzrr� ►nestron
xper. Mal Technology 133nbsidence Contmi
Geothemtal(Closed Loop) E)Ttaccr ft. ft: - ,
Geothermal tin o 20.D G. G bawl u
Return? Odrer lain trader#Z1 Remarks) meoer To ngscan►rrav actor
4.Date Weli(s)Completed: '22 We11 6 A' Q fL I ! star
IDiI 0 ft. IL5a.�We�A Location:
ft. &
ft, fL
PacitieylOwnerName FacifltyID#(ifgrAlcabie) ft. it. i
skid and zip
ft
ak
County Parcel ldendficadon No.(PIN))
56.Latitude goat t i L 1
Wwoil field,one Intl M is ss�dem) nt�t/seconds or decimal de�eea: I I �•
W
6.b(am)the Ivei1(e) ent or J>tnporary sign`oatnro f
ell Con emr � Date
7.Is tills a repair to ga exMng well: Yes or o 9y ak*K ds farm.?hereby c0r*?lull the 1tv'10 urge(x+e,�l co�,rrrred ta arcordmtce
{Jthis ire'Wafnivow brm w"I/eonatracdon with qfi15A iS MV O2C.0p00 or lJd 1V a lb QZG'0200 HWI Calu twWon Standards and Owl a
rxpairunderii21nm=tssectionOranthebacko�t/opandexplatnthsnatatneafthe spy+0'7hisrscat+dhas6eenprovidedtorheiKwowner.
I ,loan.
&Far lien 23.Site dbgram or additional well detells:
probelDPT or Closed-Loop Gmtliermd Wells having the same YOU may Use the back of this page to provide additional welt rite details or well
comslxttcgon,only 1 GW 1 is Maki Indicate TOTAL NUMBER of wells construction details, You may$tso attach additional pages if necessary.
drilled; _
I Total well d 5o lo S't3BMITTAL trc- (ZS
epth below land agrface: (D•) Z4a 1<or n W
Formnl*k wells?!stall depths(i f&mt(aaa;; 3Q200'mtd 2C7a 1007 -�b Submit this$lam wittier 30 d
qs
consirnctioa to the following: I•
ff' of completion of well .
10.Statle water level below top of eadog; Z.0 ( )
uwter?eweris above cairn&use +� `` Dividon of Water Resou�,Information Procaft IIn%
11.Borehole&meter. r 1617 Mail Semen Center:Rdd4h,NC 276991617
�) UL Far iniectlon W ttp is additian to�to�seeding the farm the address in 24a
I?-'Well cansitraetion method: a I r it above,also submit oat copy of this fam►within 30 days of oompletion of well
(i.e.auger,mmry,cable,direct pasty etrn) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Under onnd Injedton Control P maDI,
1 1636 Mail Service Carder,ltaldgh,NC 27699-1636
131.Yield(gpm) Method of tat: b a_ Z4e,for Water SuN a*•:��,,fton R'o. hi addition to sea
ding 13b.Dtdnfection type: i!I I 6, the address(ea) above, also submit oae copy of this fbmn Wititia 0
Aatount: 0 days of
completion of well constmodon to the county health dqm tptent of the com ty
where constructed.
Fomt GW I