GW1-2023-01953_Well Construction - GW1_20230227

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Jan.-29. 2018 10-:58AM Env. Health No. 6711 P: 1
WELL CONSTRUMON RECORD!GW 1� or Use Only: , (.
1.W Contracto Ioformad
WeU Cattraertvleame t O t DI3CRIF17DN
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i"wen Construction perrrates 47 6( DAM9M. - 31MERr.r
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3.Well Use(eheekwu die): n• n. tn.
WaterSupplylvell: FROu D`— - -MWEIM aw a MAIIAuti-
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Geothermal(Hentini;XanlinaSupply) fd=WaterSupply(3ft0)
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Egeriman d7echnologyr 13SubsidMControl &
Geotheamal(QmedLoop)-- OTracer saD �7Si� iadri iiuscmi -_a==
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d.Date WellO CompletelL 'a wen m,,/ Q� itoiy.
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physiratAddrose,City.rmdTrp to rE
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Cosaty- perrdlydemifidtionNa(P121)
56.Latitude aad lottgltude 1n degreesimiDntes►uctmd:or decimal degrees: - � •
OfinellBeld.anolu!latgiasa�eient) O 22.Certifreation:
6.Is(are) e-weli(aAPer n-naw or nTemperary 9igmrtaeo dNfenCon i Duo
Byb@mng this ja as Iherdby eoq&char the t xW t„ar iirae)rnminured m aecotdonea
7.Is ibis a repair to aD eaTatingweR: 13Yes or OTo -riih ISdNt:002CAt00 or lid"OIC.0700lVdt CeAmegi aShbemdt aad&of a
• {/r<Jttsarrpal,JlRoelra,w.wrlrmAan,eGaamJanvan ardd�FlaDtlhenaum►Of& �PYojditrrxaordlmrbuuprorrdtdrot�smlfomra
l/pNf�Fdtr42l nam�krrruanwaAthl tmeYojrhlsJOtet. .
23.Site diagmaz or additional well details:
k For GeoprobdDPT or Closed-Loop GeotheraW We Is having the same You may use Litt:backof Chia page to provide odduiomt.KJl site details or well
construction,onlylGVi►lisneeded.lndiattaTOi'ALINMBHRofvvells coastiucliondetails.You may also ottacbadditionalpogesifnrettsacy.
drilled: r milimiTTALMEZI CTI"em
9.Total[Pell depth below land sariaeet J G S pti.) 24a.For All Wdisr Submit ft form vAO&30 days of completion of wall
FbrmtrAp►d�v�lts!>nalTd�+h,1 +( •3@ana•a„d:gtaa) conmuctioatoomfollowing: I,
10.Static water lad below ropateesiog: For (n•) DlvidoaotWaterReao UM,
Information Processing Vn%
fjwaroNewtuabmceaorm&foe+" IQ7,17filServl4CeeterdMlt1gh,NC27699-1617
A Borehole diameter:- -(In) 24L For inlecllon Wdlr. Ut%dditioa to 4cndkS the f amm the athima in?Aa
e 12.Well constrneilon method. �() r 1 above,also copy of ems Am vmhm 30 days of completion of well
(t.e.sage.rotary,uble,fuee1 purA do.) cons Onto the following:
DIVWWn of water Resource[,Underground fnjecdon Control Program.
FQR WATLR SUPPLY WELLS ONLY- 1636 Mail Service Center.Rateigb,NC27891636
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13a.Yield(gpin) Q Melhod of test: .i ��" 24c.For Water Sunniv&Inleetlan Wells: In addition to sending the form to
the addtess(es)above,also submit one copy of this tort Within 30 days of
13b.Didnfecdon type: Amour. completion of wall construction to the county health dtgtartmmt of the county
Where eonsbucted- .
Form OW-1 N CmnlmnDcpvtmmtafFa omneorelQmbry-D;v aaoflNeterRcsatem� Rv4md2-2M16'
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