GW1--03294_Well Construction - GW1_20230512

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WE C N t7 T10N RECORD 1GW-11 For Internal Use ells
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2.Well Construction Permit it fl. te. - b'.
i.W a l appftmble tedfrn 1wvetIon pmaws(1.e.111C Comity.Slain Yartanca.cue.) it. ft. ID.
3.Wen list:(cheek well ase): 17.SCRR• una suriattsi.
Wilier. Wdi: mom- ra E1eh atrium 77itC1
q el f M1sticipal/Puhi'to 0 lr D- I"
Geothermal(FlweingfCoolingSupply) pkesidential Water Supply(singlc) ' it. it. in.
liulutltial1Coemmercial Ditesidentisi Water Supply(sharal) iss 4.1tour Sr
urt+� urseu►onstavr nn
4pM I!
trtigutian I ra 2D � 1 1 1�V.Q-
OWIT
NonWater Suppl_vWell: 1
Monitoring ORecavety ti, fr-
nleetlofl Welh ft. R
Aquifer Recharge ©(iroundwatcrRcntodiatiun 19&PIDIGNAVEL PACKfitsanlieultlet
Aquila Stefan*VAG Recovery OSatnuty Beata _mom To too- e. rteutatopir Skillets
AquiferTcat DStonnwaterDrainage
fr.. n-
Ucperimental Technology DSubsidenca Control if. R. H rfl
Ctcotftiamai(eased Loop) 07taccr PRDRILLINGM O •(t�ifat6tl� s tp�wan Iwmt
Geothermal(HtatinglCoolhtgReturn) jjadterfeXplain mulct#21 Remarks) 1 ft. R t .
4-Date Wdl(s)Completed: Well 1138 1� n_�1 I ft.
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sa Well nhutaPoJpt&k'
[« it 1/2. m i
Te ,vi ,r,: 4-s—� ' l�Y`
I� 'bwn ttamc . milli,loll(if applicable) n �,I ,_�
106 ere)! win . l�Vll�. 'tfr. rn r2gN it:r4
physical Armen.city.and 4, i 1\„cu v t` WC ,21. ;MARt(S.
ft. 11-
�('�r iSovl t 1 s 2023
Corny Parcel rdomiffcaticn Ala(PIN)
5b.Latitude end ton a in hagreeslmmi icaSeroads or decimal degrees: �.. .- err X'�r"3. urA
6•Ie(arc}the weil(6} Pertranef 1 or Temporary ihnIr.
f Cartino!Well Ccatractar Data
Ise a fide,lan,1 hereby owt&that the noire)era fuem9 ermorrNM in acan►darce
In late a repair to an Wien well: E3Yes or�,}No rah lea s iC.[.'9M:.QIOO or IJA NCAC 112C.07Q0Will Cwntracainrr SYamdenis and then it
ifddx icarepeI, Al emblem mil coaairre rreyin penertoIL eXprole themom gf+he t 1VYaldOS reef rd heAbxa paged te the weet nwtta.
me*under A21 raFlat=d nareaerebartnflbt form.
23.Site diagram oradditlottd well dent*:
8.lrnr Geoproae/DPT or Qpsed-Lnnp Geotheram)Wells having thematic 1'eu may use the back of this page to provide additional well site details or well
cone niction,only 1 Gw•i is needed. indicate TOTAL NUMBER orwells construction details. You may also attach additional pages ifaaxnary.
drilled: _ (Fs- (1�M11Uj'J ei,llti7RUCT10N�
Total'.l. well depth below land salaam ( ) yeti.jfor Ad Weft Submit this Than within 30 days of completion of well
Far andople weer lit![di&WAS•Ifdyen:nr tamp e-3itsab•and:@loa1 a estrectiantothaf flowing:.
1ft.Static water level below top of wales: •- - (it:) Division of Water Resourses,Information Processing Unit.
If rater low 1ls i*tivu cwIn&ale'."
/►I q 1617 Mail Sllervlee Cmter.Raleigh,NC1 699-1617
i i.nonmetediameter: w I (!n.) ?Ab For 1.terliop Weller In addition to Ong the fain to the address in 24a
mta ` above,also submit one copy of this'form within 30 days of completion of welt
12 Well construction method: . construction to the following
(i e.eager,men.cable.&eat push,etc.)
• (( Division of Water Resources Underground Injection Contra/Program.
FOR WATER SUPPLY WELLS ONLY: J 11t36 trlalt Service Cetttrt J aiZRtc3g4 NC276+J1ii1r36
13a.Yield(gm 1 Method of test: VI LI _ 2:ie.For Water Stoutly&fnlecHan WNhu in,addellon to sanding the limn to
the address(es) above, also submit one copy of this loom within 30 days of
13b.Dlstnfectian type ,Amount: completion of well construction to the county health department of the county
-• where commend. '
Form GWI Moral Carotin Department ilftinvitihihbcotiii Quality-Ohioan oi'Weer ltotoirces Revised2 22-2616
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