GW1--07301_Well Construction - GW1_20231109

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2.Well Construction Permit#: ` "' FROM TO D1AM R Imams MATERIAL
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3.Well Use(check well use): R. ft. tn.
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Injection Well: •
0 Aquifer Recharge DGmundwnterRemediation rt. ft. •
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Ss.Well Location; s c �11t C>�^_P,f� •
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County Panel ldeatineation Na.(PIN) - ;e `;;'1d; ' "• "
5b.Latitude and longitude In degrees/mmutes/secondi or decimal degrees: '
(ifweU&W.cuo Inane issufficient) / 22.Certification: 44Sa
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6.Is(are)Ikeweli(s)0Permanent or [Temporary 9t8mrtaeofQemSedWcRCoasucror Dale •
By tigning this fain{1 here6y eelary that the trall(t)war(rare)eanUrrererl a,accordnace
a 7.Is this a repair to an eslsting well: ❑Yes or o with 11ANCAC 02C.0100 or ISA NCXC 02C.0200 Well CoanntalonSlandmL and that a
fells Is amps(,Jfioutbrownwell een tructionbfarmarion aid esplaln the nature Mho. copyofrh/s tecordMs bw,protidal to the ivall owner.
weir under e2l renmorkt section oron the book of this forrm. , .
23.Site diagram or additional well details: •
8.For GeoprobelDPT or Closed.Loop Geothermal Wells having the same You may use the back of this page to provide national well site details or well
construction,only 1GWWr1isneeded.Indicate TOTAL.NUMBBRofwells construcfiiondetatils.You may also attach additional pages if necessary.
drilled: /'
(� /� SUBMITTAL INSTRti, 19N4 -
9.Total well depth below land surface; /\ (ft.) 24a. Par MI Wells; Submit-this farm within 30 days of completion of well
- FarmnWple warts fuudiero+hr(Maw(emmpte.4200•and 2(a 001 construction to the following:
10.Shute water level below top ofcasing; CO (ft.) Division of Water Resources,InformationProcessiu Unit,Ifwaterlevet sabovecurbs&use+" g
1617 Melt Service center,Raleigh,NC 27699-1617
• 11,Borehole diameter. /3 1/4.,1 On.)
246.For Imlectlan Wee: In addition to sending the 6onn•to the address in 24a
12.Well construction method; P 01r - above,also submit one copy of this lbnn within 30 days of completion of well
(Le.auger,rotary,cable.deed guilt No.) tD the following:
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FQR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground[Walton Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gptn) fri Method of tern p,pe--c 24e.hili For Water Sunuly&Infection Wells; In addition to sending the form to
-i zi the address(a) above, also submit one copy of this form within 30 days of
• 13b.Dittnfetdon type; t.f Amount: of C9,C completion of well construction to the coiatty health department of the county
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where cottsttutted.
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FormGW-1 Moth Candi=DepvtmedtofEavL,emedtel Quality-Division ofW eal:somees Revised 2-22-2016-
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