GW1--02915_Well Construction - GW1_20240510

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I.Well Contractor lfforfuation: : : :
' 4. For intern: Use only.: ' : "�•'`
:: .:Chris-King King : : : : • : . is '"; . : ;.:. • •:: .'. :" :. . "
:Well Cbntroct2 ume.
• •NC Well Conirociar Ccitificaaon N
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-. ' ." 2.: a_eoppllnii c.t io oPermit O �' • :- ,- - . CAGING OR•TUBING' T . •-od closed
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-3•Well Use(check well nee):_ ® +�Tur.•
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( g/•oo g Supply)" .a kcroident(ai Wutor'Su''1 si le
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: :• •. I Im ,Lion: :, [Residential Wtitcr Supply(shared): • • �"'• ® "•"
Nan-Waier3n Supply y Wei :. • t&
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'. Iglection Well: • ovcry. •
R•. BINPLACB._ _ hIBT110DirM10UN1'• ' .
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a Aquifer•Storn o • ::- Mill1113111111110.11111111111invimms•-:.: '..
:�Qroundwatcr Rem�iation
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�11hcpenni.. •Technology •
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., �"{�ilCll lili#. • ••._'',' . _' �DESCRIPTION for lam.
. Ba:Well Location: ' : _
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Facili ioi ofaPplloahlo)'
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• :';:. .pbyahpl Addis;City.and Z_' ® - F'.� 9• i '
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County A,. y" •.n• 024 .•:'
Parcel Identlacattoii No.(PIN) '.: '' '
Sb.Lgtitude and longitude Ind ecs/min'utes/seconds or decimal degrees: •" - , y ,• "� ' .
. . :'"• (Irwcu;lletd."nao latrlonII��m�n:) : " • ' �+eece.: • :. • ..
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:.•.7.is dig t.re a:r to.. .. '" . . . •'.": Data P . oD ealstiti• ::. ®1/e9 or �To. '' •• •'Bi•signing I/jls fnig.:I Gernln"iry •.yxy rite arll(x)nix(nerd.initti .
"1.l Ia a trep•p/l to kn esl aril well:-.- 1,e0l..•or and ee lal Me stature• rhr":'.' n - .
"repairnar/erri ' filly11ANCiraU?L;p100nr1JANCAC03C.0?0U!fillConria• :..n51a• •• • •• unrf•diala•"• "
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• S. Gcoprobc/DPT or CloseB-Lou •• • ,•
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p Gcotht t t �Velis 23.•Sited Ingram 4r addidonnl.Well detaW:
con For Cio p Obei ' 1 C'nseded.-ladt • • .
• "drilled ' cute TOTAL NUMB R awe!, •c'oonstnletion deialG:Yo may.alsoe • • .
� to pmvIdo•additional igell site dotttils or well..�� �•attack additional jfntuy;..
• 9.Total Well depth helots lead surface•• 4• �- IyST$UC170NS
For Total
W l cl p all(owlems U}d Ririe.
(PLO fa!: • "' • (ff.). -
!M JD anrl_rlelUO5" 24a. o. • •'.:• .
1R x All r tt.' $nbmit alas form within 30 days of"completion"of:welt
•• 10.Sgge ss'atcr•lcdel below top of easing "": •alttvirr!arilsahbtrct1444l usi•it . .
• con9tcttction to tho following:"
1 i.Borehole .:•
rr Water.ice Ce ter,Raleigh,N 27699si"" U
diameter: " .fie? .' (In.) : •• • • .•
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- . ;.1617 Mall Service"Center, NC 27699-1617�.-'
•t2.Waif dth tion:tietltode•. % 24b, • r" tlo ' e :. In addition to Sending the form to.the ad .
(i:e auger,nary,sable,d�.ct :above;also submit one co dttrss in 24a : '
: aovn:�ion to the followin▪ g:py of this form:within•30 days of completion'of well" • "' •
• " FOR tVA t Li2 3lfpPLY V►'ELLS O`tiY:" ' � .• • • • • - . .
-• ' ..• • ••Division of Water Resou• rces;Ignder- •
13a !'+eId( t>•); • •• I636" •Mall Servlt�Centerand Iglectlon Control l'rogr ,". '
•
Method oltes, . �: Raleigh,NC 27699-1636 " . "
.3h.).islazi floe;:,sere• . ;. • " . •
• T.-,�-� .'?4c. or titer Sotiuly 8s necion-Ne11�E Lt
- Mi•:. . :e ddr (Ce) above. also•submit do Cop
the addition to sending flip total to
Z• . comp!. ton o Well constriction to the ant hea tt d* 'Wttltm thedays ty •
1'oirtGlFa. .. . - • Where constreeted. ' , y epartricat • '•the county;. •'
Noah caroling DePantttent ofl?niiro 1
muenW Quality:Ditieiae of Water Recuu.o