GW1--05893_Well Construction - GW1_20230918

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. re re. I ND Well Coritraor t eniloodon Number
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2.Weil Construction Permit it / ` 0 mime To mom* 1 :TxtcratEss MATERIAL
liitaappl mbtewell ro uuvrcnm permte(Le UIG Comtry,State,Yarian t aim)- ft tr. lo. I .
3.Weil Use(deckled use): n• tr. tin.
Water Supply Wen: ritiSCREEt+ --_ _ a 1--4.. �,.,,-F. :•._:._:^ • .
MOM TO MAWerea siorstz= wenn= riety STA1._.`
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Geothermal( alN€!Ca:>ing Supply)- QResideanal Water Supply(single) n: a to
dustriattComauxciol - 0Resideutial Water Supply(shatod) _ -
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nwM to MAWRIA1. I _EMPIACEMENrMETHOD&Anse rn
dorm-WaterSupp(yWellO - r ra 1, ti _ _rr I •
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Injection Well: - -
• _ AquiferRecharge In GniundwaterRemedialion R.- • -
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AquiferStoiage and Recovery pSalinityBeirier PROM To MATERIAL sMP1dCJtMRPrriR780m
_-_ _ -Aquifer'tlest }�StotmweterDrainage A.. _ fr. - - --
. ExperimenmlTechnology EISubsidenceControl d le .
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4.Date Well(s)Completed: S,� 3 Nat IDtt. �� '�, .'-
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Coumy Paaelldeditiatoallo.(PIN) - I• •
Ste latitude gad longltnde In degrees/nloutes aeconds or decimal degrees:
(Jewell field.enaterltangrostl6eieat) 22.Certirreatima: 4,, g' - (
.7 S.3Go 7 7 2 N V o /%/ 4/_ w k1,1_ &I Adie-vi y^l d -1
6.NA(are)the wags) Permanent or [DTemporaey 9ignstureor-certified WelConbacmr Duo
aysipthl dne jbmi,I hereby cook then thl wall(t)wet(mere)commend a,accordaaca
a 7.Is this a repair to an existing welt OYea or rpa,.r • with 1SdNGC 02C.O1t1D or 112 NCI 02C.0200 Well CmimnaxroaSemadatdroad that
If this isamat,fit lmurnownweltmwruetiowWmmetionoutI ego)lhamatmv Mho CoP Mktg romid tin ban proiidedrofheirslimmw.
repair ono er@2l noun*aeon Orentha Sod-o/ddsfoms I .
23.Site diagram or additional well details:
S.For GeoprobeMPT or Closed-Loop Ceotheranl Wed,laving the ammo You asp,use me bade°tibia page,to provide additional.wl(site details or well
construction,only I GW-lisheeded.Indicant TOTAL NIMBHRofwells constmctondetals.You may also Mach additional pagesifneceremy.
drilled:
SUBMITTAL INSTRUCTIQJ$ -
9 Total well depth below land surfaces -7G_5— (h.) 24g,For All Wain Submit this farm within 30 days of completion of well .-
eonsnactian to the following
10.StadeWIer level below top dosing: /-S- (R.) Division of Water Resources.Information ProcessingUnit IJwwarer level it above umwgure+"
1617 Mail Service Cebtes;Raleigh,NC27699-1617
11.Borehole diameter. 10 '4.4 (In.)a 246.For infection Wells: In addition to sendntg the Fiant•m the egrets in 2Aa
12.Well construction method: PaLLi('I (( - above,also submit one copy of this foam within 30 days of completion of well
C ua tags.cab!g insect push,gift) ram/ COnsttostionw the foltmciitg:
PAR WATER SUPPLY WBIIS ONLY: Division of Water Renames,Underground Injection Control Program,
1636 Mail Service Can!i rRaleigh,NC276991636
R �13e.Yield(Qptn) Method ofreWt: /0i pe ltr 24c.For Wafer Sunbiv.�Infection Wells; la addition to sending the[oat to
Gi the address(es)above;also submit olio copy of this farm within 30 daysof
1311.Disinfection type: 1-r Amount If ' ? completion of call constmcdon to the coturty health department of the ncy
adhere canstiucted
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