GW1--03098_Well Construction - GW1_20230428

) q-
NCWtOComtit r Certification Number
- 11 .: :OrVIER ASINGItii r0 '-- -•11.01 nirintOrir* -blit-- —S,t tin?
ROf' S li..kli aGGct 1, Sei'ui.e. t! f, �zs j ; • nuT w.
l 5}DRa i!c
/ / r6.']s11s1El if ORTUMita!{nth ureied:terli :e."447W ..
2.Wdt Construction Permit*, l tuOM TO OrAunerett .ra[cra
�,Toeur
list ell a
pplfrabf•xeRromaaanaapermtn(Le.WC.Camay,State Yarianu,Nei' Cc fr. lo.
3.Well Use(cheekwell use): R. tr. M.
'Water Supply WO • trtneREEati _ :'= . :� ..,.. . ;AV :;_a•V • •
ROM TO DAMMER SOTS= THICKNESS MATERIAL
Magdalena' • lr ,• lefpaUPab&e 0 rt• rt. to.
3 (gm6noU Supply) ri '-identiel Water Supply(stogie) rt. a tn. -
1.Indus6ieUCommecial DResideatial Water supply(sheted)
Irrigation ="IScGRQttT'� tiw:.�`Z__��:.€•�� �-=-��;.��.,.,=.:=.�.r.�;, .
PROM TO MATERIAL EMPLACEMENT METHOD&MARONE
YOn.Water Supply Well e rt. S to t• t ;k v -int.rs1/i n,r
Injection Well: _ R. _ _
• p Aquifer Recharge 0GmuadweterRemediation tt. _
- XteninRnvrainewatF.ern n6le)::.,__44:44:,:L.:.�..vmr.: .,q; ,.. •
zttAquiferStcaageandReewery ©SalinilyBarrier TROM To MATERIAL clar.tantetriuenton
n.Aquifer Tat f Stotmwater Draionge m tr. ,
)ExperimearelTechnolagy ` DSubsidenceControl n. b.
'Geothemael(Closed Incp)::. D1lacer s MI'li TB'•1s3 Midi eadloeiuibhe'et:- iiiicOniiy t=g —: ; ••
,(:.nauni„ir(Hcn r(,apliiigltenm)
IQher(eglaiiunder$2Romano) " O D faNaror ul '"w"dc-27 "thuia ! -
! U SE c l�y
!.Data w (s)CompetedY`�'r�sa Well IDt#., Ca
tu 7.5- f 6','`gt-+e-7 -e •
_ � ZCjZ 6/�r/1 Gr�'. fe�i'e
J' '`~ —Sa WeltLoeationr
a-PSu$SwjeAea - J7(2j - ft.
Psenity/OvaerMame Rake Mg(if cpplieafjb) ft ft.
tot Za-PotTeAd 5? 9,i,C . ., - re n. • APq 2023
tin 4PhystreiAda t,Cov,sad to - _ re tr. tit,,
'l,n6a 5-r %_a/ nrnir lrs.: � -,---=w-:.; .. : ,aZ\_:;
Cowry P adla tar.rionNo.(PIN)
Sb.Latitude and longitude In degreea/mlantesIseconls or decimal degrees:
(ifwat Md.oatkeens&sa&cient) 22. 4,4 g a- a. s'sv .J 3 C N V zi `,1—t, •�G wCertifieaGcu:
J - n - flu, 0 `f-e?s-.23
6.Ware)the wells) Permattent or ['Temporary Ego:ma a edged Well cancer Daro
7.Is this a repairBy Wiping d n 1 hereby with tfrar the we)tray Omer)eansnrresgd b)modem• to so*skiing Yet or iNo ®ire HdNGCO2C.0100ea ISr1 YCA 02C.0200 WelllCoasrnratonStaadomdt and that a
f this ttw riming Iorebrowtivdfronuruweeh,Jama%ooaudmpfamthe wawa efrhe crFyoerh&meant has ban prowdtdroths lull owner.
repay meter a2I;meth section Oren leek ethafere%
23.Rite diagram or addinondf well delatlsr
8.For GeoprobeiDPT or Crowd-Loop Geothermal Wells having thesemp Yoe may we the back of this page to provide additional veil site details or Well
construction,only I GW-I iS needed.Indicate TOTALNUMHHR.ofwelis Construction details.You may also attach additional pap ifnecavmy.
Minot
�DG S1mMITTM..ttvsrltClC,rlt l
9•Total well depth below land snrfaca (h.) 2mt.For All Wells: Submit this foam within 30
For mpWPaewetsiwalld hrrJdpe e<,t(em�►e.3�oa•arrd2®1aa) days of completion of Wall •
i constructon fo the following
10.Smite water level below top of easing: G 1 (IL) Division oMWaterResourees,Information Proeesstug Unit,
/jxmerlaeelUcbmwa,f,eg ore+" 1617 Mit Service Center,ReieIgh,NC276994617
11•Barehote diameter. 6 14.4pa,) 14b.,For Infection Welk: In addition to sending the fronts the address in 24a
12.Well construction method: PO 41fle V hoc,also submit one copy of this Sum within 30 days of completion of well .
(in.sugar.rotary.tab.dued pnib.etc:) I� constitution ro flu followmg
FOR WATER SUPPLY WELLS ONLY; Division of Water Resources,Underground fujeedon Control Program,
1636 Mail Service Cadet,Raleigh,NC276991636
13a.Yield(gem) Method often: ./ Q / .
/� pllr•.,iry 2te.For Water Sunni*&Infection Welk: to addition to sending the form to
13b.Diaintadon type_Ili, . C 4 address(es)above, far
the also submit one,copy of this m within 30 days of
Atnoaai completion of well construction to the county health departmment of the county
•
where eortr'lrtcttd.
•
form GW 1 North CmotizaDepurmeatofEmdmameant Qualify-Division ofWatracsomm Revised2-22.2016-