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4.Date W'eli(il Completed:S Well IDti O L�S1i• l aY
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Sa.Well Location: -• •
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Physieol Address,City.and Zip
21.REMARKS .
I.CAA r, •, (Is..
County Pucel IJe rxl6cabon No.(PINT -.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
fir well fx d,one W/ionE it turnc4nl) 22.Certi/fiiccat�ion
Slputu:c aContncJ Wcll Cmut.b
6.ls(are)the well(s)0Permanent or fTempnrary
9v!rgning rho form.I hetelry rotcent&iha me wont).nee rowel coonrocred rn accordance
7.Is this a repair to an existing well: Yes nr yty�No utth LIA NCAC 02C.01110 or 1SA AC,1C 02C 9290 well C.a,vucnon SiunJurda nnvl that u
(Pilo Is a repair,fill pia known will rnnaorruror Information does rrplarn the native of the toP:v eilhn rrrn,d bur hero provided to the urn on,wr.
Irywir under all remarks arcnon or on Mr tun k,,fthi,form. 23.Site diagram or addidonal well details:
You may use the back of this page to provide additional well site details or well
g.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 W-1 is needed. Indicate TOTAL NUMBER of wells
commotion details. You may also attach additional pages if necessary.
drilled: �j 5uesiiTTAL InSTRUCfiONS
9.Total well depthbelow land surface: �O` (at) Zia. For All Wells: Submit this form within 31)days of completion of well
fnrsiubiplr went for all depths((different(crumple-Jtei•2011 and2@(n!i') constnictioo to the following:
10.Static water level below top of casing:
40 (fL) Division of Water Resources,Information Processing Unit.
If water lrwi cr aim r coring,ate 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 14b.For Injection'Walt: In addition to sending the form to the address in 24a
Air Rotary above.also submit one copy of this form within 30 days of completion of well
12.Well construction method: , construction to the following:
•
I I e.auger.rotary.cable.direct push.a.:.l
Division of Warier Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mill Service Center,Raleigh,NC 27699-1636
3 Method of test:Au Flow 24c.For water Supply S.Injection Atilt: Ln addition to sending the Erin to
13a.Yield(gpm) the addressees) 3,10%e, also submit one copy of this form within 30 days of
Chlor Tabs t 1'2 Lbs 13b.Disinfection type: Amount:[: completion of well conic—ileum to the county health depa:im:of the county
who.;cunsuuclal.
Form OW-1 North Carolina Department of Environmental Quality•Dlnvtm of W'a:a Resources
Rowed 2.22.2016