GW1-2023-02809_Well Construction - GW1_20230417

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I.W I Contract° Informa / . - - • L� I •
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WdOContracterName MOM 4O araccxmmx
ii P - 3 20 R. Flo4. it. �Q Gam+ .
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NCW& rc
dlCeara CatifiationNumber itiAlIStiIMASIN1T(f6lrinidtiesrl*PII+1:QI EINNItttfa' ter»^:
C� 1 i.k1I c1 c( IPCt�7 �ef'-�lc`C a FROM ��L`ls ft DMNCeERP 5.0v.
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/1/O :�6�INetf austere an ►atN ttir+i7it i IaiSd l3' k� -�_ �Y
' 2.Well Construction Permit MOM TO of imam;
meta appllmbsearel1 emuamtiohpermtu Ra UIC Cowry.Static Variance,etc)- ft. rt. to'
3.Well Use(cheektivell use): n' fr. 1a'
Water5appl9lWen: rt2:3t:R8En� ..=�=... ._ -�. ..s:»:,..fit•_ ::.�—�_
PROM 'ro ; Dtancliirt SL0?StiR ThtCitNP.SS —MASERiAL
Agricultural , QM icipallPublic 0 tr. ft. to.
Geothermal(IleatingfCmra$Supply) eatial W &pply(sings) IL ft to ,- -
_Induatrin1/Commeteial °Residential Water Supply(siO4 =ono — l_. •..._._-c_ s ,.:f,,.w-
..,Irrigation FROM TO MATERIAL RSIPIACIMERTMCINOn&AMOUNT .
Nou.Water Supply W� 0 m 4 a u: , N:(.,j' 4is1/i spA rdi fAL
tiring DRecovety - R. R .
-- IojecdonWell: _. - - - fc - n. _ .
. Aquifer Recharge EIGrouadwaterRemedietion ___ •
Aquifer Swtageand Recovery OSaliaityBarrier iG1 •
airiSAWIIT3tBGP.YCK1MA A�1e).i�. u ipL10Ea1Eitt nor
_Aquifer TVA DStotmwaterDrainage $ ti
ExperimentalTechneingy OSob04.nr.Control a. ft.
• Geothermal(Closedlaop) InTracer - s20.-.10i adrittGfiit iiaatnonAirliii retiiiiy .� -r -=
OW TO OfSCRIFTION aloe aardnmaRik Rlpy ibiRet.efei
_Geothermal(Reating/Coe)ngRetu o) E)Otherjexpl°in underi 2l Remarks) O g.. . m .e. CrG,y
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. 4.Date Well(s)Completed:!'')")3 Well IDS eo fc usG i' ...eTr-G
5a.Well Loeatiom ,CIS h ycM 6.10.�e►e r
• Des 14t7t s ri._ 1C1.; Ifft. u. ,r _
PaciitylOrmerName Punks,mkiliPPlizatn4 h R. (•n.s ;'' `
/42 m4,Y/ -f:a i(y . a R. APR 1_ 7-2023
Physical
5y09/11 � g-7a-oa 057.2 —Jm
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County PtRalidentideatiooNe.(PIN) - G°'''`.;f 0i= J
• Sb.Latitudeti and longitude in degrcess/mhmtesli�ecomh or decimal degrees:goad � a
e a•) (J(rfla N otm Wang broaden* d p• IZ fa W 2Z eertil'wtion: a3. l
6.Is(are)lbewel(s) Fevmenent or Temporary Spume or errifiedWeIIConaecror I ltd.g.4644 1-.-i 3:W 2
Date
Byeigning this form.nerdy co*that the ua111e)my(kere)oamwated at oaadoace
A 7.Is this a repair to no dsisdng wets: piles or flhlo with HA MAC 02C.0100or LIR NC4C;01C.0200 Well Coam:ratanMaadaeb and that
flails isarepalrfl0ani a:wencanumaionhfmamtaonanddgoraOsmeanMb coPY gift Mimi/asbaertprowwded toMewl/oimer.
repair ender @21 renwls maim,mranthe backa/thrrfarm. '
23.Silo diagram or additional well details: •
- S.For GeoprobelDPT or Ciosed.Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
• coestmetioa,way l GW-1 is needed.Indicate TOTAL.NUMBER ofaslls watuucnoadetails.You may also attach additional pages if ne ammy. _ •
-
drilled: •� ;DBM TPALINSTRiUCT/O •
[7 9.Total well depth below land=fans G 0 (!t.) 24a.For Mi Wells: Submit this form within 30 days of completion of well •
FarmauplexdirlutaQ&Ai Jdighma(eserie.3@100•aed2@100')
. construction to the following
10.Statue water Witt below top of caling: / (ft) Division of Water Resources.Information Processing Unit;
pram,Imetit above caring um+' 1617 Mail Service Center,Raleigh,NC27699-1617
11.Borehole diameter: ii) 944 (lii,) .I 24b.For inieciton Weill: En addition to sardarg the founts the address in 24a
12.Well construction method: PO4ar f '( - above,also submit one copy of this form within 30 days of completion of wall
Cie sumrotary.cabtc.dheat purl,eta) v' construction to thefotlowin�
FQR WATER SUPPLY WELLS C ONLY: Division of Water Resources,Undergrodud injection Control Program.
1636 Mail Service Cepta,Raleigh,NC 276991616 .
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13a.Yield(gm) Sr/ Method of test: /) k--.&4 y ?sic.For Wafer Snub&Infection Wells; In addition to sending the form to
I U / i .e the ttddtess(es)above, arm submit one copy of this form within 30 days of
13b.Disinfection type: &!r Amount: completion of well const action to the county health depanment of the county
where constructed.
Form GW 1 NoRhC,aolmaDcpa d gate[FAT•+t•arytQuality-DiYisionofWaWRom=I Revised 2222016'