GW1--03652_Well Construction - GW1_20230526

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WELL CONSTRUCTION RECORD Mr IntarillrJseONLY: !
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1.Well Contractor Information: t U.� &MS i . 1
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NC Well Contractor Cerei&oation,umber FROM Tel atAMx3TElt TH1e:KNE� x►rAT rAr.
AIAI`tt,C &la 11.1ii_u k PvwArP G ft •140 ft' Ai l2 hi. , SE,Q t7 , PVC_
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Compeey MumI3 ^� maw TO DIAMETER Till .MATERIAL2.Well Construction Permit Or Al A. 4' it. , it. •
UV all t�lknbte well pe O&I L.ONIII,ate,vmimrce,Nal=eta) e,, i is
3.Wen Uses(cheek well use 11••�", x .. •
e.... TOM To ( DIAMETER (mars 2Z I BEICKNESs I MATF.RIAI.
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ttlndusM;.UCoenretereial °Residtential Water Supply(sh®red) -Lt,t1w111.•'o ' :••„,iwzsae�r •' rasee.AcdMmrrer$rnn)aanima
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Wags Welk ;,t91 AbR?HX1$l.t�lit i[ e � •
p� Recharge DCtoxmdvveter Remedietiol mot ' to �A uE nwpmea21>Ikriai anon
ElAgnifor Stems mg Recovery OSo1mity Perrier • a_p' !a l (_O rt, fit/ gf(VkveL . 3c3 Zeb
DAgUiferreft • UStormwatcr Drainage fr. • ft.
I:Experimental Tcc httology OSubsidenlce Control
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DQ all1E1 nut(C1osc oop) ctflacGr limn • To IMIC tu'rwrttwar,Weans,w1Vr+sltays+4e •ui,•va
t oleothennat(lfeatln 'ootmgllatwtt)' fit:idler(teplain under MI Remade) d 1 /0 R' .5d44,b 1'CU ,
. /o tw 14 reTe('r+4cb 1& c. ei-ky
4.Date Well(s)Completed:.5//7/2.Well ION a.e.) fb info ft CLAY/SNeEL-/Sc ► ear 'Aw,1 t
So.Walt Location: , AO ft•, 5'0•. 6,.e,C t(g i ggE.1. - ,
1. ..i2y may).. C-70AV& Sew u' ./GO ft' MO. ere 4 Y sakic /ss-1 tL
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3 AM Rocky&-k l .i N3 o e.(r N.C.X?4 31 a fr.. o' ; ', , -
most mow,grit ondZip 31.REMARKS . . k , .••.'
Cl-to 44-i MAY .? g 2023
Cow. Parcel IdeotliealionNo,(PIN)
.. 6111 Luftado asd lleellgltado ID dcgnewndd utes/moude or decimal degrees: 22.Camtlon: f 33t�i F�'Jta
Of wall Bold,one iaffiofg 0aufficlent)
3 C..1 .583(0 x ' • 67 8o 5 w d '14 k� '�—t-r
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si ofCerti4ted Well Corametar I '
6.1s(are)the wettish permanent or ❑Temporary E,*wing nbte,thrm,I hereby cer46 than the well(e)was beets)constracted in accerdnnee
with I$ANCAC 02C.0100 or Met NCAC 02CA201)Weil Crewmen Staniar*and that o
7.re Also repair to on existing wets: Mee or No copy(Phis mord hag been plaided togs yeomen
refiner is a.molt:Ado1inowo wail aaarowciionWorntmlen and cohti n As Mum ofiha 23.Ste diagram or additional well detellE
impair amder ens remark sectiono.a.rb.a�kCl t>:v�„e Yeu may use the bank of this pa to provide additional well site details or well
IL Number of weds constructed: construction details. You may also attach alditulnal pages ifneceasary.
FormerNpls brjaction or non-maw etg*Welk ONLY with the Mlle co. otx you can ►SUHh;Q1, AL 1N8F[)CfIONB
ar,A,ett �6,,,,.
9'Petal well& eL below bout serfaeot I r./ (ff.) 24e.For All Wens: Submit this than within 30 days of completion of well
Piermdlnpte wells rkra7d ttdi( rh pts•8 O'medV1007 construction to the following: 1
IQ.Made water level l below top decider _�p i a r Y (ft) Division of Water Ration,*tn1hrlmatton Professing Unite
Irotorlerel a above na,e .,.. 1617 Mail Service Canter,Raleigh,NC 2769546/7
ti.Borehole diameter: 9 (in.) ' 24b.For Menton Wells ONLY: ,In addition to sending the form to the address in
24a above.also submit a copy of this form within 30 days of completion of well
i2 Well coostruceloe metLoas M.GrA q9 T%fay Colffitnietinll to the folk:wina
(ea.=Fr,=tarp cabtq dime paah,ego.) Division of Water Resourees,Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: •
1636 Mall service Center,IbaWgb,MC 27699-1636
Al 24c.peer Water&linty&infection Welt:
13fl.Tit1t1SRO /611 t Allittadomen D.ca-V- Also ulnnit one copy of We form within 20 days decatPletionof
13bkDioit�fe dontyppes�trc�tLo2iT Arnow* 9 Oz ' well conatructtcn to the county health department of the.county where
constructed, .,
FormGW1 North IlmlinaDap ut of Etwirononc and Noma RCKJaocs-OlvslanofWatcrR®wuresa Revised Ana%2013