GW1-2021-03746_Well Construction - GW1_20210823

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WEWCONSTRUCj<'IUN gEt'.;ORD{GWI For intemni Llse Illy:
I,wellCantrarenrInformation: -_
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Well Cantracior Namr
VC Wctf Co/nt�rraor CatlficMioa Nrrtniter �011'ffsR C RING �ma OR R��a MA'Cti�uL
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I.Well Cnnntrncrirrn Permit#: in,
ids?all applicable 1oa11 r nmfmcrinn parns/ls(i e.IN:C.rmary.Stale Yarlanr:t7 etc.)
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I IYCJI Use(check well user:
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Agricuittiral anicipotlPullk
Geothermal(I•ieatinglGxAing 3uppty) Resideltiai WaterSuppiy(single) fL
lndusrriat/Cammareinl Residcnrial Water Supply(shared) .
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L"xperirnd:ntal Tcclmottrgy 13Sultsidcncc Contort
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Gcothermel(Closed loop) [)Tcaccr 20•011,11.1.11 id AtowreRrt o ere.
Cicnthcrm.1 iftatinpJColing Remm1 Oilier eX rain under i121 Remarks} t+ROMf tr, M
4,Date Well Completed:lU____?i 2-1 Well IN _�, �zb It- -22 tt"Oil LarAtinn.
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1'it i sil�Addrec's,City,and Zip
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Canary Parcel idemilicntion No.QW)
5b,Latitude rent lonfiltude in degre siminateNsecandsorglecimal drgrees:
6-wglt field(ona 100ang is auincicnt) ('ertifiLr
(.ls{arr.)theweU(s) Permanent or DTrtnporary tiig vrcwalCmrnnemr !)ate
tR),al}mini" I hrnrl rVW1fjr that qir,Wdt(a)was!94W4 rMAMe win aaHrrlaace
?,ks rhos a rrpalr to no existing well: OXnS or J;YNn /Nr iSA tiCAC`A2C..?Jl1b nr 15A,VeMC.11?C.'.p2110 Well C4rarrnairr+r Yraadar to oml r>tm.r
lfdrlr ix:+rclmtr.fill the anmov afnce t apir of JGts herd JrarhPM preiftf to the WWI r l"mr_
ryarm trndcr r?l rzmrVkc yCplmr ornnt/n 1rurJ:nffhls,jnmr. 23.site diagram or addlional well tlelgibr:
R.For Geoprni,r/11PT or gnlaad-1 onp Geolharmal Weida having nc�same 1?4X1 mayLrse the tmcR of this page to provide additional well site dem ll ih or we
onnstnrrximt,anlh I M-1 is needed fn4icW4 TOTAL NUMBER(ifwrlls concttiKtiDn details. You may Also Mulch athlitianol pages if necessary.
driUucl:--�-.______- _ ���� d,1 •rrrA1. j`�' i�..CITUP)S
9,Total well dtepttt below land surface: �td! _ (Q} 141* Fer Ail AR: Submit illis form tuition 30 days of completion of well
Reirnorhlprcxv11r1itra1lA!pgceifdllfcrrnr(dram/Hc^9(n1lUQ'andi(rr�lOR� ronAlruBiianto the ibllolsiil9:
1n,3tntle water level below top of casnpgr (R-) Division or Water Resmweea Information Procetsleg Will,
{jenlrrhnrrh•nbnnrrnsMg•va(C"•'" I 1617MAO Service Center,lRateigNNC27#h-1617
Rnneholediamctcr. `� j (In.) 24b.For Infection t,Y" L►addition;to sending fhrs form to the add[=in 240
klimm Alpo Submit ona copy of this form Willem 30 days of compleflcm of well
t c.1YcR Construction cable,
d method: lJ carosttuction to the following:
(i e,mrgc•,mhq•,cubic,dieect ptrait,ete.1
Division ofWa tir littilourcm Underground injection Control Program.
f"OR WATER SUPPJ V WFLI S ONLY: 1636 Mail Service Center,Ralelgh,NC 2-909.1636
11a,Ylcld(gpm) �r� `NOW of few. G c ! Pale.ft Water 3119MV&►akeNoQ lVtlts: In!addition to sanding the ibrm to
the odd=<es) abnve, also submit one copy of this forth within 30 days ref
tab.Disinfection type: Amount. completion of swell WAStfuCtiCa W fte C ttmly Health depatlmem of the onlinty
ashore cnnstmctod,
t4mn�'•'t Nmr1t lalrnlinns�rnnmont.if tin.9rrtmnrntnl Qmrlhy-Aivisrtgr of Wa1R Rayopfcev ReviseA2 22-2a1d