GW1--03890_Well Construction - GW1_20230609

WELL CONS RUCTION RECORD rniZ Use ONLY:
This farm Cell be used ibr single et multiple wells
L Well Contractor Information:
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Wd1 ConeustorNsues C�" /.O ( 0.44 fib. 51144D
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NC Well Contactor CerliRcaltoaNnmbor R CASINO(tuamDtZ Cidisul)Mt mot lel
FRom TO DiAMETER I THICKNESS MATERIAL
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Company Name girl �OII 16°1111 1 e711i GeHSVistr 'MAT6ai1fW
2.Weil Construction Permit*: ft. �, in.•
Listen applicable well meths ere.Minot Sue, grim ce,lyectioa,ea) ft. b,
3.Well Um(cheek well use): _17. '
raint pptgWtllrt ( ice Ta ( Dustsrn 1 sl Arsum !Tefes(NEss 1 MATERNALagricuitural Municipal/Mils
►c Ion �` '°' e >o h Pvc
• c�veeatvr, (i�eatir t i') water Supply(�« )" ft. ..
[)IndustrisUCommeroiel OReaktential Watar Supply Oared) r 14
; row.To_. . . ,-,'at4ttdi lii. • nlan cinzcrrrew>♦raoOa*Meant
ton . d it 4 ft. mtg,i'., fbe,R.rib.
Non-Water Supply Welts it
DMoniforing OR+.aovery tt ft
Iglrctlou Well; .
qAg RechargeGt;roundwnter Itemeditttian ^m SACt1DlGH'no . +7rfiiiepfA L]e} EMPLACEMENT METHOD"
CPAi,ifer gtmage and Recovery ❑Salinity Rattier • rr ft.
•b+ kf
I MOM Test O tafmwllter Drainage it.it MO / kiki- v CC':
alixperimeatal Tbolwology OSubsidoncc Control �20.DRfLLtiv(,t 11GlatteeL uidttfonaleteebt U it aryl
DGeolhemiwl(Closed Loop) DTracar t•1WM To Dg5c w toN(car,t ern,watrNth tree,Lain Owl Ilea
a Geothermal(Heetin�CooiingRceurn)' _iOther(explain under d21 Remai1aa 6 E. `� 11. �P Sa, L,
4.Date Well(s)Completed:5f3 Well tD1 14 /O ZlGfl PY Germs 15/ Solue.( f
/O So t4 GiK C,uiy/La 50440
Se.WeuLutynan: , 50 ft ;7.. ft ,612ey 54,.16 J444y Lga•SE.0
GG/fl-l' GIN SCo 6. 7o ft 8o tt o w r . .
, taeitityavtttuMsms Eetatlity D?k(if applicable) -
80 R. /00 It: Gie l r►l6b.5 i-lib
/! Sint a t2 czA, .6.-,_Nrr.2,4iI ti(.C. 1 . Poo ff. /�.o it ;;j. i i q
t'hy ANI AddtOm,Cftyr=DV, ..ZLEETh1Eh45 i '�t.c : `�!• �,y a
t:J-k0t,/Q-Ad
count, meetrdeadaauion No.(P/N) '.JUN 6 9 70?3
•
' Site Latltode and Longitude in deatee/msaulcWsesond,or deetmsl degree: 22.certiflendon:
(rfwalr Mid,one lettiong is autilcicut) information Prot:wir.'Unit
3 , .f'1 33 1 N —7t9. 717 4_ CL w •1.war-- r'l0 siva
Si of Certified Well conlraolor Date
6.]lc(tire)the meths): tliPermenent or OTemparxly >l,3tg J,e ibisArm,7 hereby cer1;that the wall(:)nws&ere)omubucied in eoeerdonae
with]Sri NCAC 02C.010 or 1SA MAC Ole AO Well Consdwetion.91ande►dbmult that is
7.L lids*repair to an tdsting well: I7Yes or DNo copy of thit record/to been provided to the well owlet:
.f this isarepalr ffeutheater,vvtUemstruotionlie5rmatienandmidi&lhcnahmeof't a �3..S4EtdjY$r8ID0lIItlilit(0n81lPClldEtallB:
.y,at.raa.,8?J,emmYb xofla>y ore»the baokq/thtrfarn You may use the back of this page to provide additional well site details or well
E.Member of wens eonstrueted: construction details. You may also attach additional pages if necessary.
Far multiple Weaken ernes wateratrpply weli ONLY with the emuseamtrrtctiots you tan SUBNQTTt1L INSTUL?IONS
er,bn,Ha„a tram. .
O.1 opal well depth below land serrates 1t - 4 (S) 2411;Fear Ml WaUll Submit this fatln within 3111 O S Of compleiltxt'bf well
eormettgee we*Wrier thighs Vd{ekrorisA..intik-A*2'e rad 4100► emeituetiontothefollowier
1a Statte water level below top deader 2 (it.) Division of Water Resources,Inibrmation Professing Unit,
rower, is „ , ,,, e ..... 1617 Moil Service Center,Raleigh,NC 27693.1617
11.lorchole diameter. 6 . (In.) • 24b,For fnleednp Wrps 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
it Wall..,...t..sstroamethods /nV•A r77-4 t`y constnxetionto the Mowing:
(ter+.auger,mvtacy,cable,dereot push,etc.)
Divialan of Wotor Resaur I,Underground Injection Central Program,
]POR WATER SUPPLY.WELLS ONLY: • ♦Gael Mail Service,Center,Rakigh,NC 27699-1636
4- C_04-r Me.,for Water SUM*42 infection Waifs:
13n.Yield(um) .5c) Method MII° ' Also submit one copy of this form within 20 days of completion of
Ci4L. Ay/a0►-t4,2j TE, anti oonaWattent to the health d � �
13b.D1st&Ceedon type: Jammu* lei t3 i✓ viaCIIIM ons warcounty
..
PttrmGW.1 Notch Carolina DeptatmentofEnvironment and Waal Roams-DIvlalenofWater Resources Revised Angtut2olS
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