GW1--04934_Well Construction - GW1_20240816

828-622-7241 13•1
I et) 1 t. 19 05;43p Gleerwater Wall Drilling ......
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Well Counanot Mimert. A. -----_
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TIP 70cror4C�,attit/c�olfon4N,nnph�e.• 0l. f . ( j___ —. 1 ML
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2.1VaN(nwatruetlon Permit#: " (r. fo.
i.1A•r oil nMr)rtvthle wall crmsrrwsleM Arran(l.u•UIG,Cnnn(y.Sale,Vai•'irrnca,WO• �,,...__._ ._..__ ft. in- _... .—_-
3.Weil iTi. cited wd1 use): m.� r�r ar.o ryltrtttitese ' T+Ut71 t1t1
W�teriuppty Wel10 __
iX Agricultural OMttnicfpolfPubiic 0 R Il_ R
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NI Ocialtcrnwl flicatinglCanlTng sttppdY) Wii�ttnl Wntar Stppl_v(*Ric) n. t+ ..
X IndirsitialfCnrnmemlai °Residential Walcr Supply(shared) !rT lL �Rvratttl UI IIrtVsiltt
apt anon ft �/ at, L f !
Non-Water ._,..s-.� &� 16
i A4tmitori : Reabvory _ . _ 1 —4
!'Aquifer Ticebtegc p(Trorrndwntcr Remedial ion P i -..,;:, -
�.ry,.:2; Cgi.P.X chi„_ra_-__
NOAgoi r Stomp and Recovery Dsnlinity I mar M i.' n
in AquittrTcct nStnnrtwntcrDralpngc , ___0----- —
VI EXperimenial Trchnoiagyi DSilbeielence Control M R. g' �.
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othcrtnal(Claned Loop) �IrarLr _ 1. i t_,.:,'I;'. ,';; ..^!f•.•:.". `_.'.- _
All Cieottiermoi(Kadin •aniing-7 ) ,/I o (explain nr#21 Rci of S) ''` tt. j� • '' ,^! 1L�
4.[late Well(n)Completed; ! -,&)/ Well OW I et Mrs , Q1
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Se Well 1.neatlnn- _) n � R �. `�,�/_P
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1,,mil Mvatmerlinito , Fadlity IDitVettpltenMe) tl, - — ---- •
ft
Physionl A An Cliy,and Zip —^
Comity Peteol khmtification No.(PIN) ..,
5h.Latitude and ltmTdtatk la deg reastininntea/sernRtam•dtrimni dram.= „------�'
1 ! z.C tics l ens, , /
(ii wsN field,W14 fatgatit in aatllelattf) �' �1, �]_'?
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tt��rtt aapaetar. OmilteJ•Wdteestraetor Rela
F.In(arc)Mr well(t�/PermRIIerlt or E,Ttettmnrary
• Aiv a1. g tom(orbs.I Iiorphy omtlfj,mer Ow ndf(.4 rm+fi+•m4 r tm.rinrelmi ro acLnrAarx•r
„volt 1 iCAC'o2C.11100 or ISA;CAC 0;?C-•.I►.2110[Volt C:tutu',mum 3/nfoiar fa PO Am,r
lfinIx''aMermenu an km4.5) elgtvNr; �}Xr.v fYo nn»,O•1Ida:,roodIinFAMIptetAdiiiineteipe(Iromrr.
tjrl,lx;.,:,rnfxrlr..Rfftxubinwnwidlaonarrt,c11pn1><Ri+mmin an}ir.FirrPA.rh:•nvrrn.tnl%hu
rrrmlrunderA21rum*=101 nronthe Nit*ofOLtv pm,
or additional wall'dittlUt;
Von may tram the bock of this pegs to peovldo additioael well sibs details or smell
k.For c:enrymbe/IIPT or Closed-Loop Geothermal Wcits NM,*fir some cnniitruG(O Tdnils, Ynu rimy 8160 winch Adtlitionnl papa If necessary,
mum lotion,only I CrW-1 is needed. 1•ttdiacto TOTAL NUMBER cif wens
dank__..... . . j J I Cdj.l( filltlt4T
alii
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n•T„t,,i wail acptA twttrw sand tttrMac: 7.f.' ) _Alt) 2.1a, For All Welk! Submit thin lino within 30 days of complain, of wolf
144'inio,Ne wens!iv aliefepqujfinsrootpromphi-"tiff owl;0100'; comnlriitairtnto the Ibllowing:
�C` _0t:) Division ofWater It sourees.lailnrmrtlon Processing t)olt,
1 n.Stalin rumor level below top of Nod Mc— T 1617 Mid Service Coster,Raleigh,pslC�7(t9l-Ih17
*ovum.our:(1,t rrfvrra rprinp.inc" ""11.Borehole distorter: a / (ln.) 'loan.J orJdertloo WAN In addition to sanding the form W me nddraar in 24o
,00Ve,Olno auhnttt one copy of tIi form within 3n /lays of completion of welt
12 Well rrnlnry alien,n method:: - annatnrctian m the fatrnwin�
rt..sager,ratify.rattle,direst pork na,1
- __-,__ Dlvlsion of S(.36 Mail Service CU1nr to Coalra)
Program.
FOR WATM C.t.'Ppta WY$LLU ONLY:
636
' EVE a I3eilt: In addition to vending the ibtm to
IJa.YklAl�plllt) , U_ --__ iM+ethrul of test:
�/ -- �tulQ Qa(CS)rsbove also submit one copy of this than within 311 days of
131xl)tsinrcction types . - Am t�nua annotation at wdt eanswction to the comity health deportment of the county
---._._.._ whore ctm nttai:red,
Form OW.I North CmnHnn t)apnrimont.of 1?,wlrr,omnn►al Qralltr-t)ioiv,np of Warr:Rcsariwio nerfand 2-2I-I01 R

Wall DOW -callelemege
keis-
/ ii pr It Pc/ ,.__.__-_
Pernik; 033;.
Ibe tbyae:trthatAbeabove mierenced wagwaygrand lu ammo=it)auco web
all County wen rules
WM maim *VA (0:67Z
certlficatediz 3 ' 7 -/� -QV
Construction: Gitut
Depth; 305 Typeczez2zid
Ceding Deg& 70
Arc; V/F-
Drive
t,- D