GW1--06288_Well Construction - GW1_20230926

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2.Well Construction t>'ermit>i<: r / Ffteart'ASIXi 4b1£TtinlNfr.�ool6 tuft )?�,,,�;; ='•r
from TO .JDIA. N>iRR i T,RI(CIQ ar.TEasar.
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3.Well Use(ebeckwvell use): • n fr. M. .
Water Slimly Well .1tiSllREEK �-:w;, ..— :-•
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AgriculturalICI�I(pD1fI1C TIrtCKNNSS wormer.
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p [t 2 to
Geothermal(B'eatinyXooling Supply) .rnieardential Water Supply(single)
TndualrialiCammeocial OResidesuial WatersuPPly(hated Q. to tn. -
Irrigation ) r'tE:-01t8U7t*`= -::� :�:'�:�.����-�_.�z�.. � •
ISOM TO -_ MAI/RIAL MI EN PIACQtry EIROD&AMOUNT
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7Djeetlon Well: - ���very - R. h.
• Aquifer Recharge EiCuoundweterRemediation ft.
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_AgoiferTest - • •- .DStomnwater Drainage
Experimental Technology )Subsidence Control • ft. Al
• Geothermal(Closed Laap):: ' )Maser • a0:D1121301 ikiG sifairiddlitaii.ihilib iteectmoi _r=ar Kam=
-Geothmmat(RRntingl3oolingg/Retura) now ender#21 Remarks., MOM TO DFSCMITION(alaraundu ro ly,udt�n bisier,etc}
�t.Data wells)Completed:,!�/�of 3 Well 1ml 9ry 0 / ` et
5a Well Loea f l/5 ft• ?.'0316 �, �a " -,-
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1:7• :� w Ve.J ,oa r 17. a F '8aerldyiOWaerMIE FURRY ft. It./r.2/ 0/in/� , ✓i�./ y a ye i. L D. ! SEP 43 .6 2023P raAica, ;t r cod rz
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County Pareelldemi6easion No.(PIN) I G4'r s" _.40
• Sb.Latitude end longitude in degreealmiahteslseeondsor decimal degrees: -
CrewenBs ltdlangiasa6eieat) 22.Certirtea6En: -- ,0 $ -
• )'toN L00 ?7 $ W
t,i_ . 12witt illidgvi 7 --) 6—)2
6.Ia(are)Ibewell(a)aPermaneot •or )Temporary Sternsmeo Deed Well Contractor • Dale
By siring this farm,I hereby web that the TWIN ism(wen)c&uwraeud Di accordence
• %Ia this a repair to a0 exlsdng wen: piles or with 1SWNCeCOZC.0100ar lilt NGIC MC.0100 NIICoarnucdofhmndo,L and dmta
girds norgafailiiorranowniv team vatontaformarienomiarph7ffifhonarmOdra coPYeta legman'bnaForldidfa gelid,elClg
rep irvtrdcra7l narark'D a oronthe barks Biafora. .
23.Site diagram or additional well details:
&For GeoprOhelDPT or Closed.l oop GeotLerasa!Wells having Iho soma You may use!ho been of dri•page to provide additonat well sine Malta or well
eonstnnctiod,only 1 GW l is needed.Lldke°TO AI,NUMBBAofnzns comriuctioadetaits.Yoamayalsoanachaddinonalpaif acades,.
drilled:
SUBMITTAL INSTRUCTI011 • .
9.Total well depth betotv.hmdaodbces C S.
„matapne.�rs/h depth
ind�/e>z r femmptQ,l I�l�) (�) 24e.For All Wells: Submit this form within 30 days of completion of well
cansntsction to the following
10.Static writer level bel wtopofcasing: G (It.) DlvlaiotiotWaterResoureekloformation Processing Uatf;
I/srmerlesblfrabmvemlu tine+- ` • 1617sMailSernceCenter,Ltaleigh,NC27699-1617
11.Borehole diameter. 6 1/4[ on.) IL
•
I 246.For Inlegtion Wens: In addition to sending the imam the address in 24n
12.Well construction method: Pawn n 1 (. above,also submit one copy of this Ann within 30 days of completion of well
(i c eager,*guy.table&met push,eta) v' communion the fotmwm�
FOR WATEA$UPPLY WELLS ONLY; Divittastaf Water Resources,Underground Injection Coutrai Program,
1636 Mail Service Center,Raleigh,NC276991636
13e.Yield(gpm) !(/ /� Method of test j�.Pt „o Z4e.For Writer Souk&Infection Wells: In addition to sending the form to
l3>b Disinfection type: t J r/ 1 ` the address(es)above.also submit one copy of this farm within 30 days of
t Amount: d C y l completion of well construction to the county health department of the county
- . whereeonstwcted.
Worn Gw-I North CmofmaDegutmeEtafTairon,nearal Quaky-Division ot'WEtcrRoams - nevized2-22-2016- -