GW1--05286_Well Construction - GW1_20230814

1.W I Contracto Informs f- i✓/ i✓�ry
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wencaiernacrlName P tz�aow�i�8 TO ft.� its-:_=orrcrn'oH= w.a wza��=: `.
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NC WI Cerneftr Certification Number
'ildiftUTERUSLV IIii m aNk107: ItI.7 7Ofa- 'hfel."n ;
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Z.Wdl Conant- don pertnit�. i �� � -�v�c� � FROM TO MAIM TAr�g xa•rpar.r
Tin ell oppl;wbte,renem ravedenpamtu It a UIC,army,Suite,Yadonet ere.)• f4 • fr. I In.
3.Wdt Tice(cheek Well use): R. It tn. .
bluer&aPitiY�ww: r27 31311 ra - -.;i s-r.=—_- -• .
�Water
tmral [) rerpaUPobfie tea. •
ro D1 Mfee i-SLOTS= •stuCitteSS MA7IIUAL
• © (g lin6o�gSupply) entialWaters ft in. _ _
Supply(sue) ft. ft. te. -
IndushiaUCammcreial DResidential Water SUM(shercd) -
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Itrigntion .&moony
FROM T(! 3lA7Et{IAt 1LIIPLACF1NSNratettiolleAatoutfr
Non lyaterSupplyWc1L• n to
3Montmring d�,ery - IL � . It. �a. �t,�r ��,r,t Wt..
In(ecdon Well:• -
nferRec a fr.
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ND/GRIVE P.CCiellnaniMblt)===F:-:.w-: ....."— 4747 .
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n_AqulferTest 'DStormweterDrainage it ft
.0 Experimental Teelmology DSubsidenceControl it R.
0Geomal(C6isedLoop).., DTmeer S20:D1 161s�Glafd;iddliiraiitie?f�'um _iii __`:_
Geothermal 1 .
1Geote: ug(HcatinglCoolingRen,m) DOher(explainuadern2iRemerks) paob[ m DrscarrtlaNftamba ,.nrna,y,,..a,",ae. -
O it: (KG is .-r.-/ 64-i1/
d.Date Well(s)Campletedi7 ‘')-
1 Well
KW (G ?�/ ft' 6,^�ri�.Pl-7 �^
Sa,Well Location: 7 a _75'!G //•0,--,PTf•'S 0J/fG0 {G it. ft a e '41 r
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. Fac0iglOwnerMAIO PdiYMg0'1apueabte Ea IL L'L
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Caeelyf Pneelldemifiodaa No.(Ma) - _ ._.:.
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Sb.Latitude and longitude in degrees/nlm,teslsecofdsordetkml degrees:
(ifwsIt bad ooeterfangissnMcieot) �}
SS� Yea N f G� a�/O w 22.certiLciiion: a1.�7 a- R
iitA. )224411-- lik,iivi 2—,26-.2,
6.Is(sre)the well() Permanent or OTemporary 9igne,meo erri&dweIIConeaetar Due
7.Is this a repairBYithing dr Aeon.!hereby ea*that the well(,p l os km)e®retuted 0i accordance
a• to an existing well: Dyes or - with13d]V AC62C.O1000rI5ANGICO2C.02d9We lCoannredonStendaxnandthata
filth ttarepatrdit1ar beinnee lea urreetianbehmegrmnandarphanshewensolthe WO'olt++r++nrd has hienprarldadto the ir0Aowner.
rip*teeter r2!wan*section aTttethe lockethtrlore. .
23.Site diagram or additional well details:
• S.For GeoprobelDPT or Cloned l oop Geothermal WC%having the stung You nuty use the beak of this page to provide additional mall site details or well
eottstmctiod,only I 091.1 isneeded.Indicate TOTAL,KlbABBA ofur.IIs consnuctiondetails You maim attach additional pages ifneccwe y.
drilled:
,G ,CimRMITTAI.INsnoterIO -
Tong well
9.Toeil depth blow land meant (h•) Zia.Par All Wells: Submit this form within 30 daysof
sbra„iu exensltnaldaira�l�Yl (er ate•a�da•andralaa) completion of well •
eanstnrctinn to the following
- 10.Stattc water laVetbelow top ofcasing: c./4 R
• Oarerkeeltrahm ensiagwe No' ( ) Division ot�vater Resources.Information ProeeutngUait;
1617 Mail Service Caller,Raleigh,NC 27699-1617
.11.Borehole diameter. 10 ���„( (Di.)
24h.For Infection Wells: in addition to sending the thrum the address in Zqa
]2.Well construction method: Pt) ('{ ( - above,also submit one copy of this fbdn within 30 days of completion of well
(Le.mgd m►ny.�.duentFARO.) v constructionto the following
FOR WATER.SUPPLY WELLS a ONLY: - Division of Water Rename,Underground Injection Central Program,
1636 Mail Service Ccnlei.,Raleigh,NC276991636
lbs.Yield(limn) _pm) 6 /� Method of test 0. r 2 te. &For Wafer SunatyInjection Wells: In addition to sending the form to
]3b Disinfection type: � !t Amount: theaddress(es)dove,also submit one copy of this form within 30 days of
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completion of well construction to the county health department of the county
where constnieted
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