GW1--06703_Well Construction - GW1_20231024

1.W t Contract d Inform - • 17 ��.2 I
b I -
WeitCnRhectorNemG esrsdurtzt1lirsty A.—..._ � .' - .6z.` +
• PROM TO DFMCRiprtop
t�� - /4 )8b9. 2c7 R /S G -
htC dlCoatr¢cTorCeati6aadoalVomUer - ,GC I %GG h /oI G/•y1 -
D f S Wait
l � y i60iblEt3CXSL�Tti'(foirmini�t�ffiIIOg �A9ERtifa htf,^ � ;o n
1 1 l (mi serllL'e 7 ro }} imams imam
cam....... : / �1J / sip l l y�/ ._ 5-.DRal P il�
2.Wdl Construction pernd n• / © , 6• ORIBIlo ared,heriva't:da'iFdfifeti..+
L1rtd1 t . l/ Rom TO 1 fir:� �—
opplimblemAemutrneGanFeta,lu(la MC.C aJADtl;tpft L
tttCrorRsq maw 41,,
•
amtb;Sirme,Variance.am) (L n �. -
3.Well Use(ebeekwell use): h, tr. i M.
Water Supply lweu 1Z?3CR8EDL n _
Qng»caltnml Q1KwricipSllPeblic FROM •rO Dut ,. scorstrc TLCCWIESS_.,MATERIAL
• QGmtheemal(8eahng/CoolmgSupply) QResideatial Water Su l Sin O f►. ;;
3Ltdushiat/Cemmetcitl [�Resideatial Water SuPP Y(h�) O tG to
-
•
3Inigetion Wit&OxCttx_ w w.�� :: =.z 7:
Yon-Water Supply Well 10. x tUaret. tatel.�Cr�tENni�an*mom'
DRecovetq h.FROM �? n 1�Ly�tvc- r,iv t ion.
Injecti
on W Well: _ R It.
• _ Aquifer Rechargo °GroundwaterRemedietitm h, { .
� StotageandReeovery �SelinilyBebrief �R •
asriSAVIV ,iYEfiPACKtttran&tit7�^FAre• ;.- m?tri ,;�;, .':;: •
ircrTcse FROM I TO NA7t RtAL siNPraCChlElYttcrnOD
�Stotrrewater hhdirrege tL (t:
&minnow'Technology - DSut+sidanreControl =-- -d h.
Geothermal(Closed Loop)....., QTraeer
klelsin)mint tiif&Saadlltoniililie fiTha iiisi _: ,1 '''
Geothermal(lleapnWCoolingRemo )101herrjexQloiettadert121Renterks) r `O DIS01�rnN(cearhanbaFsofymckyrotnIniia,tki
4.Date WeU(s)Complefed��"6 l�'p�? Well IDiF . Jos I( �u,��'G S���/G pr/�
Coca /SU GA ..e77-
5a Well Location:
,�r�- -� aUaAs- f�� 21iDty1D3f6f2apylfrtea. �rG �ft. ��� ��c�^ .� 9 4
Fr cilitylOwner tr. A. "z ,Yi f'i"y ,�bb)
• / L/ q iWWW L./v 5vri,,// . 0140 G cI '� D• (1i:1 ‘,1,, % 11123
phy3i.dAdd.t.City Sad Tip 1 d R.
Coen r palealldemi6eafrallo.(p1M - '- ... ,
Sb.Latitude and lonptnde in degreea/mientra/secoads or decimal degrees: i,
Paoli deli oaafetlongion:Meieot} zz Certification: l, a— eSG ,C7G N gli ?G ?a. (2 w � &q •
gizigd /0-/7-) ?
6.Isare)the well(s) Rerroenent or 0Temporary Sitn o edWellCoaer I Date -
e 7.IS this a repair to on existing well: Yes or o By die 1 heroby or*thm rho villa)rear Oren)eamtovetrd in emadaeea
with►SA CfC 02C.0►00 or Lilt NGIC 02C.0200 WeltCotentdedoRStaedade and theta
((due(ra main fill cud krmmwdteamauulonhfamotien and again thetrateetrthe eoPYojrhltswonthasbseepro►tdulro Melvin owna.repairutttera2 enuadrsectionera,thedeefqfthisfom,.
23.Site diagram or additional Sail deta 1st
• S.For Geoprobe/DPT or Closed.I.00p Geothermal Well:having the some Y0u trey use MC heed-of this page to provide additional well site details Or well
construction,only 1 GW l is needed.Indicate TOTAL NUMBER ofurlis conimutioadetails.You may also attach additional pages if mammy.
Millet
=buTT L INSTRttCTrO?f
9.Total well depth below land snrfacet ` 0 G
Fbrmatapkuedsorar/deptliaridsi mt(em e.3@sa0•mdze#08) A) 29a.Por.Ui Wells; Submit this farm within 30 days of completion of well
_ _ - . -. construction to the fnllowiteg
10.-Stato inter levet belt iv top of casing: t4 G_ (It) Division of Water Resow•ees,Information Processing Unit
•
fuser lail t r acnecariaswe+"
• 1617 Mail Service Cebter,.Mielpb,NC 27699-1617
11.Borehole diameter. la /� (la.)
/� / Wb,Far Ielection Wens; in addition to seeding the from-to the addnus in 24o
12.Well construction method: MO`t r l above,also submit one copy of this ibtm within 30
C. sum rotary.caWG Cuedinn%eta) cwtspaetion to the following: i days of completion of well
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underg!and injection Control Fromm.
1636 Mall Service Center,Raleigh,NC276994636
13s.Yield(gpm) !17 pJ t � G
Method of test: 1 r p;--1.tLlrXp 24a.For Water Sunaly&Inlectfan Wells; In addition to sending the form to
13b.Disinfection typo»_ � (r dmoutri: C �s the address(es)above,also Submit one copy at this form within 30 days of
completion of well construction to the county health department of the county
• where constructed.
FwotGW--I NorthCmof6mDepr umeatofEmireammnlQuany-DivisioeofWeterRetetam
Reviaed2-22-2016-
.
1