GW1-2023-02461_Well Construction - GW1_20230404

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4.Date Well(s)Completed✓°of /' Well Mkie, ,rO its4di gr Ci.oria-~
5a.Well Locations . /0 it* /Q Y.14 6"a•...e1S _.
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County peceelldemtfierdoallo.(PIN) -
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• 5b.Latitude and longitude in degreestmmllmrtcalsecoads or decimal degrees:(dw �� a-
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6.Is(are)IbeweU(s) Permanent or [Temporary 9idmlomfiedWellConaacror Date
By signing Jut faru►1 heresy sett am the well(1)tint there)catsavcra l et acandenee
a 7.Is ibis a repair to ao tabling weft: DYes or f No with MAW 02C.0160 or 11R NCAC 01C.0200 WeliCoarrnruronStmtdarots and that a
Phis Isetmooi..Jluordkmnamdt emanation e;fe mrenarndaeplaauhanatoegfrhe "Yofrhtr'mod has ton protrdurro!Ile tveIIowner.
repmrtadere2l marls:Won oroa the sarkelr orfans 21 Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having Mecum You may um the back of this page to pmvide additional well site details or well
• construction,only 1GW-Iis needed.Indicate TOTAL NUMflS1 ofaxlis constactiondetais.Youmayalsoattachadditionalpagesifnecessary.
wed' S^� SUBMITTAL INSTRUCTIt S -
9.Total well depth below land solace: CO OM 24a,Por All Wells: Submit this Iona within 30 daysof •
bbrmnmple.rant(anall&prherMemelkortgde.182Qa'sw141Q0) f completion of woll
[.J construction to the 6ol[o.Ying
10.Static)rater Itvet below top of casing: ` O (R) Division of Water Resources.Information Processing Unit; •
ffwarer Mil:rebore croft&use+" ` 1617 Mail Service Cehterr Raleigh,NC 27699-1617
11,Borehole diameter. 6 fin (In.) 24b.For Inleetlon Welk: hi addition to sending the f amm the address in 24a.
]2.Well construction method: or - -above,also submit one copy of this Aim within 30 days of completion of well
• . (x.auger.relay,Cable,travel posh.WO - �/ Caa9t:ttetWn tO the following: I -
$�B WslTFdt SUPPLY WEISS ONLY: Divisionof Water Resources,Underground Injection Control Program,
1636 Mail Service Ceptts Roteighr NC27699-1636
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13a.Yield(5pm) -7 Method of tests f3 pr�far 24e.For Water Sanely&Infection Wells: In addition.to sending the form to
/� the address(es)above,also suhmitlatio copy of this form'within 30 days of
• �i l e
13b.
Disinfection type: r amount: 3 CIS - completion of well construction to the cotauy health depnmaent of the county
f' where consisted.
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FetmGW--I Noah Caroline Depanmmtataati onmeenlQnity-Division afWaleacmmrm Revised2-22.2016-