GW1--03653_Well Construction - GW1_20230526

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WELL CONSTRVCZEONRECOR For(ut:mtgUaeCNLY: .1
This term MOO used DV single or multiple Wells
1.Well Contractor lafirmelon: It wec zit I
Imo.G,,. We S, __ oM . To DZSCRINION
Well Co a norNnmo A/O fr. M00 Itt 6i'Y sr+u 4 ISM e Li..._
Acc t•.t C 2.5Sa.-A AOU'r cASINGItku,nudism}o0Ln+»rrtolrapi�e6ie)- _ _
NCWef Contractor CettimeatioaNumber FR03ti r`o DIAMETER ttnCiavEsa MP.TiiRIM.
ACIM (2.:('PcNi Vitt-., % Pt/ a ft L'/U f % to SbR,C7 i PvC Compenytyame gig i; ,.1'6OftTU trUCt stosed311o81
/ PROM 10 mu see ,etnzawth
2.Wen Conetrucdon Permitth Ai 1 •f �j t It. ft. is
•
Lint al1opfleableWI permits G.e.00111 State,dtirtt>nrx.InticactLexc.1 0- - • Ag1 to
3.Weil Use(cheek will use)! 17,'! ( '
`wniere Supply t mom 1 To 1 O METE• I tiithtrsl ( 1 MATERIM. '
• ClAgricnituml DMunicipai/PUblia H ��,a ft, � tr. � ,v�r� No Ptie
f� 0, tu.
L7t3t rhrarrptr(rreotin�Cowmg Supply) taR {aesrdal wets Supply(,d ) • .
I]Lsduetrial/Commercial DResidentia[Water SnppTY(ehsred) < WWI'S.:eOJ._ '''''aiw4icuu►i. gin
kniSatigno ft' a.o ft. K wr., t av ab
• Non"WaterI3upplY Wr1I fa a ,
t7Monitoring .. . MeQO° ' _ R ft.
• Landon Well: •
ClA9uifbr Re born QComendwater them teduttion •• JEL Pnagt�itiWblel •
raterae !1D Au�lElsui, _BMPLACrM1NFMSr710D
t'.I/tymrer Storage tool Recovery Qgolini(y Harrier oa.C,., o' /1 0 rt. ./ 6,e AVE L PUtl of b
°Aquitor Teat i3SIBmwnter ROM ft.
c1ExparimcntoJ Tectumlagy 1:3tibsidencc Cenfrol •30.'1 PILL 7.40G(eta id.dMramdel eettineweenarsl.
❑Qeothtaimal(Crawl LOOP) Mew 'net To , dsscatrreon emir,r.+ueen.ilium*hos,gown dewier.)
CIdeathermal(}twtinl''ooticaYierart)'• 170tker(c2leteum/era/1 ROUwA a) © t, `rj lb s e►
.1A/ C L Ig y
to. lb a.° lb Fere"/SAWS/C��eY CL.6y
4.Date Well(e)Completed:S//7/.23 Well IDd N/44- _r,) ft' iic n , a Ay/StrE.u_/sc, .&LRE y s
Lg./W.-I, KA4Arr fil-tkw‘... S o ". /cc' R Mgt).&tKFY SAW) 1 S►W LE--
[+aaattftyrowil TNema Facility Wit(irepplleuble)
/co ftI tG it Cc -Y/S►t , :g, . ' t f\
A3A/j3 RcckktA Rki�b rcA.,nl.c. a�9 3� R. • Z _ . I- '`y i 9 q...
Misled Addrcm,City,tout Zip .ZL BEMA11
CiEo *1 MAY 2 6 ?OZ3
County Paled identification No.(Poo
31h Latitude and LO,1'4 I .go to dcgrocetinfoutesteccoado or decimal degrees: 22.ClTtifiPati= tnfit.sir,:,•.Es n 'r'r.-.5z"s':r:g i t
(ifwem 5o[d,ono ta070ag atttiloicd:) MVO/rs!,'Zi3
34. I 5 813 N - 76 . Ce78. 7 w 7 )6). t /i7/<2.
menu,re of Co,tittod Welt centraoto:,
6.Is(ore)the well(o)t ,:0 ermine* or DTemporaN gy.lemma this Arm,1 hardy errs that the well()tsar done)ceartrueled in aceedmre
with ISANCAC 02C11d0 or i.LA NCAC 02C.d2dd P/eiCauserndkn wand that
7.L tale a repair to an misting with Oyes or Itego copy of this morel!tat boa provided to the well amen
VIIIii anrp,air,Nout loom r+aUconrtmetknl dkn atldopilallt the nohow elk 23. e d1s rem or additional welldote ii'
„ter,,, ,a»,.,,ram,r�ua„won ek.a. �d v}�.,� You may use the beak of this pane to provide additional well alto des or well
8.Nondter of wells constructed: • construction details. You may atop attec}t additional pages if necessary.
Parsnuhtpre Lyjecaon ornon-waseramply walla ONLY with the satemnrl ton.Youcea StIBNQITAI,ll i IlCTIQNS
s.Tatar well depth Wove hand saer'aeee //D Ire-) 24a. For AV Wally Submit Sits than within 30 dity8 of completion or well
Formaittpts walls Ilarall dapitoMilant rexample-10200'card AVM construction to the followingr
to.Stade water!reel below top of eaetnst a s F 7 (4) Division of Water Rtotilmtat Information Processing Unit,
realter forego above ,ep.+- 1617 Mail Seroiea2 Canter.Raletih.NC 276994617
11.Honhole diameter: 9 0n.) • 24b.Farytieaelnu Wedb ONLY: In addition to sending the font to the address in
24aabove.also submit a copy of this form within 30 days of completion of well
sa wen contraction method: Ivly h I Ti}g,...f emcatnsatimr to the following,
(ems auger,Tansy,acme,direct push,ow.) Dtairien of Water Rnsourcaa,Undergeaand In)aetlon Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Ma Service'Center,Rakigh,NC 2794.1636
24c.For Water Santo 42l tectlon War13i7.Yield igD�W /GO moms vivo Div° Ara,cut tint one copy oflltic torso widen 20 doe of eotltpletion of
1(3ir.Dlettti`eeHon types /�chile, i ilInati111: 9 O'Z • wotl motivation to the county health d.pa.o...nt of the Avoid),where
constructed.
as'r
ForatOW.t North Carolina net+»>uad Environment aneNatmul Romeo-Milan ufwatcrRamon gavial Milan2013