GW1-2021-00943_Well Construction - GW1_20210401

1L ��1 : � L421�Il (Ivd� D�� 1�a for Internal Use Only:
1.�`lell Contt�csar Information:
Well Contractor Name -
6�G. L• iii
4
-8e 16C t
nc Well CatrlractarCer ificatrion Number M OUTER CAMG Nor OR I.1�R o
Curnminge Developments, Inc. FROM D R 'rnrclaardSs RSAI�mrAL
Company blame
+1 Ra 6 618 la. .188 C.Steel
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9—UJ N 1�rL --DGo2'� try liNfiTJERCASIRIGoltitOAt� -tclosedduo71 2-Well Construction permi .
t#: ? 0 tRtoR3 TO �BAil4t f L^eL4 P1?tl��lES9 0.4A s ettt2'L.
3;wen'Use(Check-weitM54. tt. t�
Water Supply Well: t9.SCI�IEN
ltilral M— nrAirdl $ IM TMCCatlL�48`. ATMAL
�Munlcipal/PubIic fr. t&o in.Geothemal meeting/Cooling Supply) Residential Water Supply(single)
Industriwcom aorcial R!rd i I t$t tt�r�awzsnht fct - Le —
trrl Orr a:..vaa"vale
FI30 Igo TO iviA'rs:Rn L ER9t'E�ACERBLRTPJI.rtf{fin Qtf'T Wlstcrr��tnpgily Cl�l1: o gip, � �,
ftrt t,:t mem Pour
Ir�t#aa
jection ing Recovery fls, &
W
uifer Recharge E30roundwater Remediation R
-
Aquifer Storage and Recovery OSalinity Bonier 11 Ila�ItlGieA�l.FACR a
rtR!f84 •s-1t -
"riyieilbz`i'w► LjStoriuwaier Drainage --
1 tat Technology MSubsidence Control 06
Geothermal(Closed(Loop) Dnacer 80:DlBII:i.IN sadsliti m s r
Geothermal calla Conlin R um Odle:(a plain under#2l ReMerl{s N 7+0 o nsralot� Caetroctx
Araftehmetra
2
A.Date We110 Completed:s2 i `Z Well WN_ _ _ y2 ft. ./ fL
So.MJ011 Location:
►a ` y -
Facility/Owner Name Facility ID#(if applicable) ft.
—LD-2,u'Z y�rlin 2d LNi Jf 27377 % M
Physical Address,Caty,and Zip QQ ft, fL
{�`n t1a iSir
County Parcel Identififttion No.(PIN)
Sk Latitude and longitude in deWreealminotulaeconda or decimal degrees:
Ofrovell field.on laUlong is sumcietn) '2.Csrtitica
m.issdarcl the weu(s) &'etrenanent or { Temporary Sigaat ed Wei Contractor Ike
BY slgirhrg this form.I hereby certify that the tl(s)um(wem)aonsipacted in acca daft v
7-is this st MPIr iv an ealatimg welt: 03Yes or MItlo with 15A KC Al:02C'.0100 or 15A ArAC o2C.o200 Well C'ansjmdtar,*a#dOr&and#sat a
ifthis Is a MWO,fill owkrrotm twilcnrrsnrr�ton trrformation and explain dw nature ofthe Nopyofthis rrcordhebeen psovtded to the r%ell owner.
repair under ri21 remarsbr Section or the hack gfthlsform.
ZS.Site dingram or additional well detalin:
fi.For GeoprobzMr or Closed-Loop Geothermal Wdis having the same You may use the back of this pale to provide additional well site details or well
CRt%gtrztt•.titm.ertiv%C;Eat.,l ,�;w^rAr.+. n„ia:•z:..T,vr t.i err-: rnnst: ,.s.,:a„ s: _
aeiiteo: - ........ ...... .v..... -
9 Kotal well depth/in beta:*land surface: �„ (ttit.) pia.IQr Ali t dye V Submit this forma within 30
I%or multiple weliR list a1l dl aplhs(J'd�lNreret(examlfiN•3 OD'anr12{r�100'} days Of completion of vie11
construction to the following:
10- ter l e water level beling use top of sowing:--- (&�.) Division of Water Resous sew,Information Processing Unit
IfrlalNP iNttef tR above ea ring URN"r" � way
!� fl6191b1a0 S�vlear t':erita?r,llt2leleh-la?q;3q.4r1u!_tEt9
-- --" .ex�;z v tin`) Mb.FOR!WISMAR Wails: in addition to sending the form-to the address•in-24a
IL Well..construedon method- Rotary I ate.also submit one copy of this form within 30 days of completion of well
O.e.cigar,rosary.Cable,direct pass,,etc-) construction to the following:
FOR WATER SUWLY WgI.li,lis ONLY: � Division of Water Resotrrceg,underground Bjojeetion Control proMm
1636 Mail Service Cedter,Raleigh,SIC 27699-1636
tea.Yi ld(gpm)�✓.._ Method of tams!Air Rotary ©c.Phr
..,.._,
- the addresses) above, also submit one copy of this form within 30 do" of
l3Ha,Disinfection type: N1�M Amo�t; oortipl ri of well construction to the oo=W heft department of the county
where constructed,
Form GW-i Nord%Carolina Department of Environmental Q=fiK'-Division of Water Resatuees