GW1--04853_Well Construction - GW1_20230728

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NC WelCemosi eatlliwlon Number A
:1COlnf lkenfaralH•ttie4vGaT irlaNER tf7-V,sbaria. <• Rot' S wail ibgx &A 6er(J Z�e FROM TOO DIAMETER I 51,DR TEEMS MATERIAL --
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2.Well Construttlon Permit / / / J '•. ENG;Oa ThnQ1Gnitad emut:ctos tarp ..tr-,.::i:'W :==
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Usrdlopplimbtei egeon wedenpermfir jte.UIG Cawvy.Sots,Variance,ere)- R n in.
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3.Well Use(cheek well use): ft. h. M.
Water Supply Well! ariSt •_;=a- - .s;,a-;.,eels.. ^= = ' •
room ro Dlws tfQ srtri5IZE ThrrltNPSS MATIIirAL
_Agricultural - gA,,we;e;�allPablic- 0 ft. tr. to.
Geothermal(l m�ft olingSupply) entiel Water Supply(single) R R to. -
_LtduatsialICammaoiat [)Residential WaterSupply(shared) Nat tt1tC1IT;=Tzs• Y;-m; � :r_ j,A,:::
Irrigation MOM" to MATARRIAL /MPUMMERS METHOD&.IMOUNr
Non-Water Supply well 3a/ n nlja11' sig[)er vrcL un. •
Monitoring Recovery - R. R
Mutton Well: . • R _ •
• AgelferRtxharge [(GtnuodtwterRemedietiori , rip,seenerlmilack:±7,F%- ':� -' ==�:;- -
Aquifer-Storage and Recovery - ['SalinityBarrier FROM TO MATERIAL aher.i CMlvratrIBOD-
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Experimental Technology DSubsidence Control I). tt.
Geothermal(Closed Loop) DTraeer - ,20:Z GI:da(iilieli eedlDaDelbbielr7b'ummir z,•'e`•-=i ,
_Geothesma(Rea6ng(Co(iliiigRenato mother fe loinmder92lRemetks) -MOM R 1O R DESCRIPTION ante senhack�eyttntniaaetc.)
4.Date WeH(s)CotDpleeed: '� Well IDM. G DO ft c �'`r�C lQy
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Se.Wall Location: (a. 7 R ro a15-It Grt-.r rP� ,
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Farulityl0waecName�, F ty104(ifip ruc1b) It: R.
CA/ /c/io fv.S / i)g/( ' It ,i: JUL 2 6 2OZ3
PhysiralAa�iR£"" 47 .7 R. R. InfOrsl astit^..il rPi 7e!6wrarr%a.�.i'ma.
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County PateelReed it:donNo.(PIN)
Sir.Latitude and longitude In degrceshmlahteslaeconde or decimal degrees:.
OVA Md.onehabits1es0Mici� les
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6.Ware)IIbewell(s) Permanent or InTtmporary sigoaen5eab_t_tt- Ph.W.4i.WellConnecter Dam
By hairs Mir farm.I hereby ernIA that the wee)um&ere)cousmnuted at eaeordecce
a 7.Is ibis a repair to an existing well: ❑Yes or C}No with 134NCAC 02C.0100 a ISANCAC 02C.0T00 ell Conrsnru on&aadar&and than a
{(thisisarepalr,JMardbrowrwdiordination hfam nioncudageatthem iner:he copy ofthis teconf has been pro Wd54 to 11w well owner.
aspic m�rill,tarosxr union arondis had OJi r:foref 21 Site diagram or additional well details:
8.For GcoprobelDPT or Clwed Loop Geothermal Wellls fraying the same You may use the back of this page to provide additional.all site details or well
- construction,only t GW 1 is needed.Indicate TOTAL NUMEER ofaalls conskucuondetails.You may also attach additional pages if nceessmy •
drilled: > - s mMITTAL INSTRUCTI9NS -
9.Total well d depth below Lind C S ((L) 24a.For all Welk: Submit this form within 30
• nrrindwe+rsnslwell&parlalk ( e.a(2Ita•onez®10(e) days otcompletion of well
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A ,� cattsnttetian to the fallowing10.Static water level below top of tas ing; .- /7�2,.fiCG`7 ",M.) Division of Water Resources.Information Proeesslug Unik
firms -4-- - 1617 Mail Service Cehter4 Raleigh,NC27690-f617 •
11.Borehole diameter: 6 It L (HI) A-IP I (�k 1 24b.For Toleelton Went: In addition to sending the&matt the address in 2Aa
IL Well construction method: A(,7`f• - above,also submit one copy of this that within 30 days of completion of well
(r c.sum missy.We,duvetput%eta) (�// constraetiw►to the foUawing -
FOR WATER SUPPLY WELLS ONLY: - Division of Water Resources,Underground Injection Control Program.
1636 Mail Service Center,Raleigh,NC276991636 .
13e.Yield(gpm)_ ) 0 Method duo Brut-4t(r;,!<O ?tin For Wafer Sunaly&Ioreclton Wells: In addition to sending the form to
/1 the addresses)above;also submit one copy of this form within 30 days of
• 13b.Diglnfeetlon type: Ji`. amount: f CG%l s completion of wall construction to the comity health dcpamme nt of the county
vtdtereconshucled-
FormGW--1 Ttoon Candor Detastmedtnrr:.. e.renlQsmlity-DivisioaofWoteeRurouros Revised 2-22.2016'
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