GW1--07169_Well Construction - GW1_20231101

1.•W. Contraetog Information:
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�}My onofa�rNamo • a moat tITO rsceiviroi;/ _>_ — -
13
NCWeiICo Certification Number h h I ;
J3 0DIEIV RSLi[t'EFTdIpfp'se illy: AlTNERltfa•..ta` tr = -11:
Ro" rcft)Wabz4 P z4 &rUiG a ,�j TO NAIVEran ., _ n atA mCr rt. C
2.Wdi Construction ' ot 1Ni� _den .,••. -.�._,,
Permit#: �ntge To arw� �? . Vie:,.-�;
maau4 mou treg rwetionparm(+tita illC,C aanR:SYarQ Yartnnre,eraJ fr.
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MMAL
3.Well Use(cheek well use): n. (r. ; in.
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Water Supply WM
—Agricultural [tMWticipallpnb� Rog TO • Mamma storms 'timm Rimini;
• Cmtbatnal(Heeting/Coolia Su 1 0 ft. (o.
fi pp y) 1'Residential Water Sepply(singe) tr. a to. - -
_Ltdua1 WCommcrefel _ bResideatial Water Supply(shared
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DLtigetioti ) ��QUI =:r. .`; `_ ` _".^s = t -.W
Itpply+WLll, temett AL -
YOII•Waler$ E�RL►�ItENr�lEfltaDAA1HOUNP
Recovery • � �lyir7/!' p•tvrs�fat.
niecdon Well: _ • -
it.
• Pt AquiferRechargo [(CmuedwaterRemediation h -
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- !A Aquifer sadRccov Eases rreanAnt raemafirt m abteJ -: ii
Aqua Storage cry DSalinily Denier' --,. pl4CeM�.....n B
!I Aquifer Teat - FROM m arAzeeub s!►sruCCMentriuraton
- �Stormgtater Drainage R tG
jM Experimental Technology �Subafdenee Control u tt.
it Geothermal(Closed Loop)„ OTraeer . FlamBIEIt1Nt7•ISafii aWeriddlpoaei9&eee�iitiicc_i
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Gcadtetmal(Aem;ngWCooiingReturn) Maher iotauadort�21Ramse'4 t DFSCnIPftpN(ntor. ndnear,>,Iym�kytn
2U � � �ecGae)
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-. ' •4.Date Well(s)Completed: /�'! 7'�J Nell 1Dd� 7Q � ��' fr �c.,�.,ej/�-e_
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riutoegons,
v// C ?-� WAit. 6O „fj2�—
• Pae9irylOwaerNBlae &`i • k:..? Y�'
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G F Pee77liprmlt(ifiipyfiwbra) ft. n
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Physical
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Corny Parcalydemitieatian No.(PIN) i
Sb.Latitude and longitude In degrees/mimes/seconds or decimal degrees:
anti Ram^^:reart->anfficitae)
is3.7 / ri e 03f‘i
6.Is(are)Ihesvelt(s) Permanent or ['Temporary w 9igtntreo�ke 1__ed Well Contractor I.`�� '+LJ�-Date �/ `7 ,
7.to this a repair to on misting well: [�4esr or [�No By signing
signing flit fem.1 hardy an*am the ye!' IN>IsarOwe)outlawederrd Di nutrients
rI s this dNCAC0 1C.O100or 111 NG1C 01C:0100 Fel I ConvraeuoASmndorde and that a
r epakInitutdrawnwdttormncuohhfoaoue„olydmplattitheHahn efthe coPY ethic mend has tan prordtdrothstwilomnr.repomere21nes&ieaton menthe hark eft-form.
23.Site diagram or additional well details:
S.For GcoprobeIDPT or Cloted•Y.00p CeaffiermalWells braving the mime
You may vao sho back of dva page to provide Miami will Sae details or well
conSMuotion,only l(3W l is needed.Indicate TOTAL MAR°fulls constntctiondetails.You May also Mich.oddit(onai if
drilled: - • ! °wry.
SUBMITTAL INSTRU,(`j:1 INS -
9.Tore[well depth below land s+osiaeet 4-1 9 Toter
nII well trlararld�rh:�dposnr fe lQ.3 m d2®IaL) (ft.) 24a.For All Wells; Submit this futon within 30 days of completion of well
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GlU consnned=to the Wowing:
10.Stede water level below top ofcasing:
flume rUrsi(rabm7cmilewe+' - (R) Division ol Water Resources,Information Protestlug Unit;
Id17Ilnrl Service Cofer,Raleigh,NC276994617 •
11.Borehole diameter. 10 f/ on.):
2db j?or infection Weirs; to addition to send ng the Deem the tam in?An
12.Well construction method: Po-tar r - above,also submit one copy of this ban within 30 days of completion of well
C4m8� Sscable,dited pub.eta)
A
constuctiontothefollowing:
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F�li WATER SUPPLY Waerr c ONLY: Division of Wafer Resources,Underground Injection Control Program,
1636 Nail Service Centel,Raleigh,NC276991636
lit.Yield e -
(goo) - Method of test . t For Wafer Sunk&Weldon Webb: In addition to sending the form to
13b:llidnfeet108 type 't r/ rlmoaar.� a", completion
above,also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county,
where canenucted. I I
FotmGW I Ranh C arolkoDcrottmeeln(Fatiom Quayry-DivistonatlYoter&m om
irevieed2-22,2016'
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