GW1--05891_Well Construction - GW1_20230918

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2.Well Construction Permit#: 7 FROM TO IMAKTeit r TmCiWE$8 ar,Tenrftr
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3.Well Use(aheckwell use): n tr. to •
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WeterSupptylVeU: r1Z:SERERN�* .'—_ ,:__= -1- r��, :} = - .
_AgtieulRtml °Morrie" UPoblie mat TO R. ur ewtca storstze 7iiimci pss ,.MAT!RTAL -
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• Geothermal Meador/Gaoling Supply) andel Water Supply(ogle) tr. m ilk _
Industrial/Commercial °Rdsideatial Water Supply(shDrcd) -
Irrigation WkOM TO MATERIM. EHPIAQMMBNrmenton&AMOUNT
Non-Water Supply Wells 0 - 3 p it:,. '—'r /�
e.zl iiiL %prgV1Cd int.,
(mitering ❑Recovery n: tr. .
Injection Well: I
• Aquifer Recharge C°Gmtmdweterltemtdiotion h. l
Aquifer Stomp and Recovery °Salinity Ranier i— 7Gi�VBG PA1CKneiteueali i. _.'_:- . ...`-•<""^�.7,-5-,•;: .FROM MATERIAL EMNACOIMiiTMANOR
_Aquifer Test-- . -' • -°StamWEterDrainage - a n
Expccimewel Tech:tuba 0Subsidem a Control rt: S. -
Geothermal(Closed Loop),.. °Tracer - Pso:26 IIdlF1 C•eteaiiadluozuiiAil +ciiiii-=�*t:�m� _--`a
_Geothamal(Renting(CoolingRetturn) 0Odter(mmlein wider CI Remarks) rRDet TO DfsCa�[IDN(alu ealdrea.solVretk�jene,m.gr)
d.Date Well(s)Completed: /�s'Z 3 (Id) le(e Cfy
Well ID#. ‘10 '- g'G/ tr• ^scV�-,'G GGC
5a Well Loenftona 9c� �'os. �/ G2q��'J`�2
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Faci tylOveurMame I:unwise(iripytirabte R. R. f .-;
Physical Address,Ow.aoduip . rt. tr. I T Q 9 '- .
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County peed medial:mhoNo.(PIN) - trre lPG�.Ai.r1 Pr-na'",;!n;Lt.".
Sb.Latitude and longitude in degr+ees/minntesiseconds or decimal degrees: I V C
(NTS&Id omlJmgisser ) 22.Certification: • 6 g a' ;�
'caa 7 97 N N/
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6.Is(are)the we l(s)alPermenent or [Temporary Sigmrmro milled Well Cameo Due
7.Is1his a repair to an adad Welk Yes or By tiring t fQ1 'hereby ecru,that:ice 1 Il(411,er(here)emanated.in occlude=
• ug Q °No with ISAZICdCO1C.0100ariSANCtC01CAl0U>yd/CannnralouStartdaxlr tad thnta
flt454a wain fill attbm•studt emanation bfandmienaderptatnetenafrm efdie WYoftt+hu aced Aubeeuprmwdrdrothairelotma.
Note eider 021 remark t Mellen oeon the dcekof,Mrfwm. - j ' •
23.Site diagram or additional well details:
8.For GeoprobelfPT or Closed Loop Geothermal Wells having the creme You may use the back of ibis page to provide additional moll Site details or well
• consbuction,only IOWIisseeded.Indicate TOTAL NUMBBRofuttlss . comttuetiondetails.You may also attach Widens'pages ifnecesary-
drilled:
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9.Total well depth below laadsurfacer qG J IN 24a.For All Wells: Submit this faun-within 30 days of completion of well . •
RorowlepteAntleMeg&ph!Menem(e lea@p00•Imdi@l001
contoltction to thalonowing
10.Static water level below top of casing; ?Ci (2) Division of Water Resources,Information Processing Unit,
flamer level trabo ecnyag ate+ g
1� ` 1617 Tait Service Centvs Raleigh,NC27699-i617
11.Borehole diameter. tit f! (In.) yob For Inieetion_Welis; In addition to sending the farm to the address in 29a
12.Well construction method: A)4A.Y` - gyve,also submit one copy of this than within 30 days of completion of well
(i.Me.May.able#Seel plait eta) . oarwtfuctiontothefoIIowiog i
-- Division ofWater Resources,Underground Injection Control Program,
- • SQR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,lbidgb,NC27699.1636
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13e.Yield(gpm) 1. Method dues fJ y.f};�pl[f •ic.For Water Supaly&Minden Vella; In addition to sending the form to
• 13b.1)ietrlCeetlaatyllo: j !/ Co the eddress(n)above,also Submit amej copy of this form within 30 days of
Amount. completion of well construction to the cotinty health department of the county
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Fame GW 1 North Carolina Doorman!atEstiamitual Quarriy-DivisionoffterRemmens Bavised3-22016