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HomeMy WebLinkAboutGW1-2022-09380_Well Construction - GW1_20221010 ,Y�t,Nlti t L WELL CON -TRUCI-- RRCORD For hdoulatU8t3—ow I.Wen ContmelDrInboun ian: L k h o � Yd.WAM 1Valt CflahsctorName FROM TD .�.NO ov &' Wall c�c�.cti:�tz� t�yC:, NJ r � G?soM TO DINME Z� /� MAMMEAL CoajpaayNama �' -I8S 16.1'>!11� OR tGetty� 2.WellCamsfractionPermit: _ &&J - D AM To IDL1 n List all applicttbfewefl aonsnrtcrlaapetmits(ir.I/l�Corettq,Stag Yariaaca,eh,� S. L im 3.WeII Use(chewed tsq)r ft: f L In. WaterSapgjy Wear 17:5 Agdcultural �M{miclpaUPubllO N 70iur►�e,s, C1 fr. rd fleothertnal(f3eating/Cooliag Supply) ffK=dwMsj Webs,Supply(single) � 06 tn. tlshiaUCommercial DResidemlal Water Sopply(s'har 18 G80t1T IM oa t:RM TO t�rss, ter atnmtnu►vr NM WWI };p WeHr � � M 'eadon Wen: AgatfwRs*wV �t ouutdwaberRamediatiaa ft; ft. AgUlfbr Storage lad Remay 03"wBaffier � �o Aquifer Test EfStatrnwaterDminage - BXPRIltewTedmology DSUbmdetwCbMuI ft: f Qeo>itetmal(CtosedLaop) DTtacer ZU. LUG:ath vhaddM aiu:e�' (ieothecmel olio ReMm, Other lafnxmder#21A adm) °M ass�ox wear 4.Date Wens)tlewgded: f5—2 -2—WeIlIDp ft, tr. . 5a.WeII Lt{eation: fI, go �t Faulty/OwnerName Facitity ifapplicable) ft. tL ZZ7/� � D•"I��4�t L 1, 1A1 HAIJ SAl"s I+hystaelAddte�.t7its,midtip 2!'rs"R2 �. � � .r. 31s LaMade and I de In (ifwelt Bald.nee taUl d�c�/miaates/secoads or decimal degrees: e 22.CertiHcatl t 3y• S l�s3S3 x 7Q. 7zd �9n w g, 6-b(are)ft Vd(s)Q,fM=ent: or Memporarp of�ed ell Date 7.Ia flits a regaii•Gt:an 3y sfgrdng thfsjbmt,l hereby are wrli(s)war(swn)amunurud In atamdm cs e7dslingweli: MYes or COW Aft ISAACAC=4100 or-ISA MC 02C MM V911ConsMc7imtSmndm&madras 1jthLslsaseputrf,Uauthmmwellem mcdontnfunmdanaruteaplatnrhetm=ofthe COPYR t T> hasbsocpfovfdedtathes+zitmvnw; tapatrwtdcr#ll rdmarlssm Van oron the back vfO&foam. 23 Silo diegremor additfaaal well detail 8•Bbftr Geoprobs/M or Closed-Loop C•,eothern al wens h wbg tits same You may Use the back of this page to p uviide additional well site detatis or well oonstmation,only I drat-I is needed, iadicm TOTALNUM ER ofvvdb Callst mof m deWL Yan may also attach additional pages UMCU M. drifled: 91bta!well depot below tend surface:_ .1(n�7...i.._.__. (ft? 248.Abe F �11 We11s: Submit this tinm wIlhin 30 d of ormatdptewe&&tatrdepthsyddjeronlemwte-3@ZQa'mfd2@IaD5 consFntctiontfl�efr Subm � �pletionofvion 10.Stodiewater level below topof casinga � ) Division of WaterR Ifunferlevelis above casing,useOr,o A essurcahMnfortnatlonPnmm&gUn% �j 1617 bMService Center,Ratetgb,NC27699LI6117 11.Eorehote _ (�,) 24b.nor Iafectloa Mas: In edditttm to sendtpg The farm to the address to 24s. M Wen eo=t=nan method:- J96A.rN above,also spbmit one COPY'Of tttfs form within 30 days of completion of well (i,�aug�mtazy.�duectpaslt,� coasf�aotioittothefnIlo�� FOR WATER SUPPLY SPELL$ONLY: DIvhlan of WaterHesooiaees,UndetVt+eaadli�ers�a t;em:nt Pa ogzam� i636 M��ta�G;e f:�ter,8atelgL:NC�'164Af 636 13a.Yield(gem) 0 MUM ofteft � yt��Zr/i+d fi{r WME ftM&&InijtM weft In addifiou to sending the form W 13b.DLslaRod3on /� the (eo abav� silo'submit am copy of this form wifi&30 days of bmm AmaoM_�!/CJc�,Gas conshutdon tD the caoa y beaft department of the coonW FoaaGWd NoftCaambiaDwamentdFEw4n utatai Qasfity'DivielanafWatprge Bevtsed2,U2016