GW1-2021-05515_Well Construction - GW1_20210805

`;'Print'Form`'
NVrLL CONSTRUCTION 11FCORD(GNV-1) For Internal Use Only:
i
1.Well Contractor Information:
�rna-(t` 1'nJ{•t5 `IA.tYATF.RI.O;VFS ' ', -, ', - i -_
iROM TO I DESCRIPTION
N'ellCantmcmrlVnmc R,M Q U C tl p r_lq fL
NC Well Cmumcrar Certification Number 1.1 OUTER CASING' far mutti•cascd wells Oft LINER61'atinficalateli-
Cascade Drilling, Lfp FROM I To DIAatFTFR TIIICKNFSC I MATERIAL
fL tt. in.
Company Name 16,INN ERCASiNG'OR'T DING fireothermatclosed-lno
2.Well Construction Permit#: FROM TO DIAMETER =1ICK
Lill all applicable wen enn.omu rinn permits(l.e.U1C.County.Slane,Variance,etc.) S`,f ft. a R in.3.Well Use(check well use): (L ft. in.Water Supply Well: "19:SCREEN;},OM TO DIAMETER SLOT Sm7.E THICKNESS MATERIAL
Agricultural �MunicipallPublic � tL tL in.
Geothermal(Heating/Cooling Supply) [3Residential Water Supply{single} S ft. n, in a a
industrial/Commercial Residential Water supply shared G(a. SG S o2 1`tl e
C.r pP Y( } 't a;CROt3T^�:� "
Irrt allnn FROM TO a1A�.R1At. • ~EMPLACEMi.NT'MET ton&AMOUNT
Na Ynttr Supply Well: tL SD tL
Monitoring j3Rectivery S0 tL R. J
tnjtct'on Wet": /r^' �f
0.
FL tL
Aquifer Recharge QGtoundwaterRemediation I SANDIGRAVELPA K if liable c c -
L�u'�ifer
e and Recovery QSalinity Barrier FROM ,
MATFAiAL EMPt.AI'i;MgryTM
�StormvratcrDrainage (�� tr s3 rL EnIOa
Technology [Subsidence Control rL R. �losed Loop) OTracer '•2n:DRILL1NO LOG'attach additional aheris irHeatin Conlin Return Other{ex Lain under#21 Remarks) FROM ft it.Tu DFSCRIPItON reiar F„a»�,brureru 4
A.Date Well(s)Completed: WeII ID# 7.S—N t-J A. 2
® St.Well Location: ft. fL 1
-or 4 1V ue t 'r • t/-f•. rL AL
Facilily/O.mi,Name Facility,lDN(ifapplicabla) A. fL
470 a, agd n 14 P.4 /NC aM it ff. rL J tt
ssl
Phyamd Address,City,and Zip a rL I forma ,.As
/ 12r.REMARKS,. a
CountyPastel ldentsficstion No.(PIN)
5b.Latitude and longitude In drgrtestminuttstseconds or decimal degrees:
(i(well field,aim latilong is sufficient) 21.Certification.,Aj wC 4 S;2f-A
4 -1*- 2/
Signature of Certified Well Contractor parr---`---
6.ls(are)flit etil(s)IIrmantat or [3Tcmporary g d nm IhL, inn,/berth seen rhui ihr.wen.r »at Y•R R Y fY () (were)comoructrd m acew'so e
wtih IJA NCAC 02C:.0100 or 13A V('AC Olt,'.fl.V0 R'et/('orurr„auwr 5w■bate m»f rA n a
7.Is this a repair to to tsialiah+well: a(31'ts or n, a shin murd has heen rovided nit the»e11 owner.
Ifrltia is a r"tr,fill ow Mane+»ell conr"In"i0n I"or"o."anJ"Plat.IA*farura of the f4 / A
repair unJer fill rrmorlr mils"or on Ihr larcA of This Jam. 21 Site diagram or additional well details:
For Gtoprobe/lll'C at Closrd•I oop Geothermal
You may use the back of"page to provide additional well site details or well
8. .Vella having the same construction details. You may abus attach additional pages if neceswry.
construction,only I GW I is needed. Indicate T01'At NUMBER of wctis
drilled: �ln'Irlt,+,�t,�-I ��c-cicl�s
t
9.Toni well depth below land surface: uG' ((L) 24a.!or All V611. Submit this futm within'30 days of r mptttmn of well
/br multiple»xUr till all dqululfJ!9errnl(rsumffa•J 500'arjja100') eaiCstnutionto the GNlowing'
of rasinE: llhitiof of water Resoarti.%►aloraistlas Processing Volt.
10,Static water Irvei below top (f�) t617MaitSersietCtsttr,VAitig%.NC276a9A611
If muier lewl is ahin+e rainy wa'+'
11.IIorehole diameter. rerr 1A ba For!flee- �U. in»�i W�iag die form to the ad itess in 2#a
(ice) aM o also submit one copy of this form within 10 days of completion of writ
12.Well construction method: cousliwtion to the folLoWing-
(i o auger,rotary,cable,direct Ptah,tic.) D(a{siof of Water Reaon11'"%Vadeig afad tajeetion Control Program,
[r0[t 11'ATEIt SUPPLY N'BLI:;ONLY. t636 ittaimnice Ctptet.Raleicb,NC 27644-163d
Nc.j 11r 1Yatri[SuDt+lY.�tnleciinit N1'cits: in addition to sending the fnctn to
13a.1"kld(gpm) itittbod of test: she ty)sti,, also subma`one copy of tMs form within 30 days of
compktion of writ C;It rucron to!Ole county health department of the cmmty
13b.Disinfection t}pe:, Atuoout wlKlt ct+itsUwted
NcwtlxCw"as Drpattrsarru otEnvirv------------
"'ait+i Quality•Di%wwn of wales Rcsuurtes`
Raised 2.2T•2016
Form OA'•t
t
Scanned with CamScanner
i
I