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Home My WebLink AboutGW1--05894_Well Construction - GW1_20230918 I.W I contracLi formatl - - I er� ( (Nis/be k • wdICoeeattorN•rne -• M To -DFSCRIPrION;' - a1:0 q - A s Q L LIC/ fe' U`-hl NC KellNCWeiICoiCati&mtoaNumber ' OU TEICAS INIi(6Drli ftlitalel MEW— '71....-`4f.eatn-e...r.5 or S ► :tl a6c l. i Serrlle e Film m a" t H3 nu L l7� Itoia �GQ • 2 Well Conargetlon Permit fir. f 'aifar ett Asip oATtin1Ng .drmnruddt k... .te.,�: .f.7 : IRoat TO WAM I. ; Ttk s =TER... Gitallapplimble ye!1emutmertonpennes pe VIC.Cl aany Sate,Yariance,ce.)- • R. h. !II* ' 3.Well Use(deckled use): • It. fr. ta.' . _ ✓✓ 1tiSFovnNt-_�-:�_- s=::- �� , i:.�.-:- �WuerSgpplyYeu �Rou TO DLM2 _ 51OTSC . �- MA7nIAL _ • Agdenitural QMgnicipalWablic .- 0 n r im Geethesm ngireoUSSupply) nimeatialWaterSupply(single) It f, to Industrial/Commer+cial DResidentialWaterSupply(shared) _ ---._ • :'tactiROilT.:- i-".:c�'•-om'--:4:�:�ver.+.-t¢:-..~_;:..»_..-xs.:�rr::'ic=>... _Irrigation RRDII TQ a1MERiel. .. BSiPucmd6NCHEfiro; aMOIAi' N on.WaterSopp;*Welb ft. _?G It r s trlk ib).rv1esi ifit.. IDIMon • oringWe : ❑ ay R. . R 1, . • AgoiferRecharge' DGmundwaterRemedietion fr. ft. Aggifer$tOtagemhdRccovery �SatinityHerrier • T-lva� '��PA 'ThSWitYncii-F_..-is�lC- y;Mrr1;:�;,;.-: - • FROM TO MATERIAL; ellQ iCiate vritteisfoo -Aquifer Test • • : -10Stom water Drainage - ft. it. Experimental Technology Dsubsidence Control - f` R. - • Geothamal(Closed look.. DT:seer 33p-pA gr (. ridltaiiil tiiiiiai ether M. = -t . Geothermal(Aeatingfaanagmom) D(hherggjtlafn(Inder#21 Ramon) 9R@it To ovsouvrtoN Wan hndana afYmrkDywjanti sar.etca ll l�' -G m o/CIG� ' d.Date Walks)Completed: 16 3 Well mg. /a - z f G t-1 =e/ -e So.Well Location: 7 q m co..m 6../''P�--r-/-E ft. Pttall OwnecMame ) fz y(_^ "1 h1 PtuaityIDr(�opyt;cg, II. i r a . 4 / - t PhysicalMao;City,endEp m R. ' SEP 1 8 ZUZ� - 6� Al • 3 S' ,c j - ::,----- - ..�..w......... __r,,ter: �f•��ta,�rA�arc�_�.._,-:. te _ =:��-,.�,:...��..�,,,.......��.-.r._.:. County Parcel ldemi6dtiaaNa(PIN) 1 inf :rfatICtl er,^.-•c wC�•�3 lit:: • r.A; i✓via Sb.Latitude and Webb ln degrees/minutes/seconds or decimal degrees: Orwell&Id.welullangiawffieient) y� l 1 . ?red° :CfCa N q//C2, .27c& 22.CertiGcattons �1,�7 c�S a- a &Ili- ak,(44 57.-/ --... ./ 6.Ia(are)Ikewel(s) Permanent or OTemponey Simonet) miffed Well Connector Duo Byliking Mir form.I hereby arb that the t di( tsar(ioute)contanrasd.b madam • 7.Is lids arepairtoan existing well: DyesftMSdI or QNo we ICO2C.O100erISASVCO2C.0200!YellCaarweiton&tWorth and tha/a hisitanpairdlUara hymnal eantrrualattWa aarianmrderplaerthatram►Mks cA1'trfte+dlmtbsenprartdefn,lhaitefoanen rapeirmdcrVItatuarb section man the back othisfam,. f ' - 23.Site diagram or additional well details: • • 8.For GeoprobeeDPT or Closed-Loop Geothermal Welh having the some You may use the beck of thin page to provide additional well site details Or Well construction,only!GW 1 is needed.Indic='1XQTA4N MBBR°furls construction debits.You may also attach additional pages ifmemory. drilled - - --- - - - - SUBMITTAL INSI•RUC7•IZN$--- - - -- - - - - 9:Total well depth below badman: °0 (ft.) 24e.For All Wellg Submit this from within 30 days of completion of well • lbrandffplevelts(trta►l&Argld1 tent(aratap1e.30200 mrdV100') eonstntetionto the fnIlounng: 10.Sfatic water level below top of easing: (� 0 (IL) Division of Water Information Processing U _ • Ifwarertaittr abase cma&we+` B 1617 detail&rNl*Center;Raidgb,NC27699-1617 • 1.1.Borehole diameter. 10 /JJ // "T (n') 24b.For iniectton Wells: hi addition to sending the&um the address in 24a 12.Well construction method: AO Y't ( above,also submit one copy of this Am within 30 days of completion of well (ia maintain*.table.ducct push,do.) - �// construction t0 doe f0ltatviag FOR WATER SUPPLY WELLS ONLY: Division of Water Rclomcel,Underground Injection Control Program, e 1636 Mail Service Conti,$9leigty NC 27699-IG36 13c.Yield(llpM) c. Method of tesC f'.p,,__f lb, Zeta Far WRler$ungly&Infection Welk: In addition to sending the form to the address(es)above,also submit one copy of this farm within 30 days of 13b.Disinfcctlon tYPe 1f Amount.,, / Cr) completion of mil construction to tho county health department of the county where canstr toted. Form GW 1 North Guara:aDepatm,eatatEnvimmaeoadQoaliry-Division of Water Retemees • Mina-222016_ .