GW1-2022-10157_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD fibr fnww UK Mr.
1'6h fbrm hen be used fhr aingle er multiple Wmis
L Wr11 Contractor iahr mstlaw
It WATER NN I
• lw1ES T 1 ' _ - FRoM TO Bl3CNiR?lON
i
WellClontramarNmro O R' G R' CO
AIcvetC 2.55z-- A IL
NC Well Contractor Certification Number F OT Sfl�Q rm 12 �teID+ L a 61e
O To olAtNETER TRI 1HATBR1Ar.
J4A%&l CAAA ULE iJ 4 .gip o I o f1: 4 la
compow N°°'° AnIGOR
2.WellConstrucdouPermft#: 379 73 s Ltstalloplldable wellperndis Ae.Catmty,a 11000.lydredon.tkJ �
3.We11 lUn(check weR use). f7
TO I D ME fine MA
OAgriculturel 0Mtmicigai"lic 80f log IL I •0m !L0
OCroadnarmat H m fi 1 dwWW Water 3u [G f6 •O I C
( oatm�Cvol• 6 uPP Y) PP1Y(s,''�')
Qlndustrial/Commerr ial QRestdential Water Supply(ate) PAQ.%°
TO IAt. E rdC6 SMr B AMOUNa'
clihilzation Q ft5 ft.
Non-Water 6"*We11: A f
nMorthorins Mowery fL fL
Injecdon
i7Aquiff:r Recharge 00roundwater Remedirdion ••IL PA, Feabk
anON Mk L MPUCDAR"Urmob
nAquifer Storage and Recovery OSgtinity 1 AM& 920 & �00 n,
OA4uifer Test ❑3=W=Drainage o. .
❑EXperimentai Ttchrrology OSubsidenco Conkoi 20.D>triLL atateb atteeti
000h=W(Closed LAop) DTfMar fROM To o c[trrrroN weu ■ .u.
r](�eothormal lreatr col' nOter a � L ft.d
aft
4.Date Well(s)Completed- �f' / Well JIM tf. +flf
Sa.�Yd1lmCat�n: R- O R- drlA (n#AV S'-004 CdA
0C&,"S t e ft CQAET_ 0 R. fs. LL AKPb f t
mft"
ama � � t� t.
2 ro,atAmbSouC /oo COW& SAS K 0 S E y D T a�_C_ fL fL
Phyeka!Add-ens,CSty,and Ztp 2L, Am
C/*aj l , cillm—esmp arm
caunty Parcel IdentWoution No.(PrN)
6b.L OW&and Logttuda in degreee/udaue al'eeconds or dearmal degrees. 27 CernBeation: N Q V 1 0 2022
(ifvien Held,one townfS sumclem)
3 L 7:,1 N
SigmtureofconifioaV4ellConurwWr D%NCWIM Dot
6 Ia(are)the weR(s)t*ermanent or OTemperary By sWffg"firm,I l emb cony rkm dm,rrn(4),=Awr4 oon ar,ied In aceanbw
with 15ANCAC 02C.0100 or 1SA NCAC 02C.0200 Well Coneftaft&arsdv*amd OW a
7.1e tills a repair to nn eAstlag well Dyes or *o copy of Aril record iron beenpm 1ded to die well owner.
1/'tht,is a npntr,fiLour hrrmw,!veil cw,orryNloatgJaraarfoa and o*kl r the aaliar gflhe ate dia$raffi Oi addltbinal Well dctail8:
^ tr yal,Y re....ate„arm,At baokq/d,tsjorn, 23.You nmy use the bank of this page to provide additional vieli site details of well
0.Number of welts constructed: oonstntation details. You may also attach additional pages if necessary.
For mddA*b0ecflon or nnirMater aWJ*wage oNLYwith the same coartra Wan)bu can 3Ul3MtITAL IIVSTUCTIQNS
arrbnvtt au,e,�»+.,.
0.Total wen depth below land surfacer 140 AI JfL) 24a.For AD Wags! Submit this farm Wlthffi 30 days of tOmplei ion of well
Poramiltpterrsl/airsla/ldepltu�dg mrot(rxaalFle-J(�306'mrd2�106) conskuctionto the fbilowiag.
to.Statte water level below top of eastnr.....�,40 EZ 00 D1vU101 of Water Rcaourem Information Proeessbsg Unit,
(fwaaw�ra abwm�'m , 1617 Mail Sarviee Center,Ralekh,NC 27699.1617
�f
11.Borehole diameter. 7�9 (ta.) UL Rar lnadon,Wa4a ONM In addition to sending the foam to the address in
24a above,also submit a copy,of this form within 30 days of completion of well
2x Wdt eowtr..H a ..tbod.-, /jCy b 0"r construction to the following.
( m@ln,rY,ea6-e,rl-,sot pmq eta.) ..r
DfviaYaa of Water Resources,Undergraand Injection Control Program,
B'OR WATER SUPPLY WELLS ONLY: 1436 Mail Service Center,Raleigh,NC 276WI6%
24c.For Water SMON&Mecdon WeW:
13z1.Yield($pm) /00 iYktbod of tcaC �_Bd A6o subm t one copy of this Morn+within 30 Jaye of completion of
E A44%uv .KY��Alrf. well comaucdon to the coumy health dep moan of the ewmy whom
131L Didafeedoa type- Amount- q .0 r- consthrcied
,a
Form GW-1 North Cuolina Department of EmMmmnt and Nataaal Resources—Dlvisfon of Water Resormgs Revised AuguB Z013