GW1-2021-03903_Well Construction - GW1_20210823

Feb 1519 05.43p Cleatwaterwell DO ing
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t,Wr.11CAntraet lnformattoo:
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C:WotiCnntnrtort.ettificatfon14Mb ���AC G �
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2.►Yell Cnnstrudina Permit#: ff. ft in.
i.t ri all applloablr wall Cnrit'rrnerlMl 1arar4x p.4 tJ11:C.anniy,S1n14 Varla VP`atul ft tn.
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3.Weil lice(check well Ilse): 17. tro A
a ter Supply Well: p.
AsricultutalMunic oUPuhiic
Creothern al(tieating/Cootiag supply) DRaidential woof supply(single)
indusirial/Cnmmereial C)Residentiai Water Supply(share!) g Ui` f"LAC Gatt at Dig tM
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1rfi�RarlOn rt„ �
Nan Wnter%upplyKrll: p
Monitoring Recovery
(njcetl�n c91: R. n•
AquiferTtecharge E3araundwsterRetncdistinn "39 ATII)/GRAVBLPA i. 1Ncitroa
Gdinity Barrie' iv?
A0ferStorage and Rceovery E3• i< ly,
Aquifer Test Ostrurnwater Drainage:
Lxperiinental-teeltnotogy [3SuMidence CAntMI
Crcothermal(Closed Loop) DTMCCX xa.�iRtt. NEW
ea.
Cieotl<ermal(HattingJCoolinA Return} �"LQtlter(vtptam under 821 Remarks) ft. fa _
a,tlatc{r`'e11(s)Cnnrtpleted: Well lD1f
7 R. (! i
.^,u.Well Loraenn" �
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htcilit►:'flnmcrl+lamr. �a--altl//y,,t--Dit,,(ifnpplicabfc} '� :� �„°..
Physiml Address City,mtd Zip Zt pv>vtAF
County Yaneel Wntitication No.(Pih)
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V.'05
51).Littitude and longitude in degrwJrnimttcs/seeonds at-dceimal drgrees: -
(ii aaolt(ic�d,ant:lat�ang is anflic'ent j / 121
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6.ls(atr.)the%vell(n) Permanent or DITrmpnrary ipnot r.of(krtrfrcd Rl I Cnrttrrtaoor `
R.,t+atJraiall►hnr.li err,I hM!hv rwrifj+that thr,WdIrk)tsar fit. L ramsrmeravl to° 'r�1°+cr
7.Is this a repair to an exWag well: )Yes, or El�o it tN,i5A vr•Ar'07. viov err 15A,VC.AC,.O?C.O=Well Corisrmctinn SYWw%`de mnl rhw a
1)'Wr ix»repair.Jell nurJinntvn rodl,rovaumulan Igformal/oaartd crprabi tbr.nan+n rrthc
copy of ibex rovird pac?vr/NDVMW la the Wd,nxarrr.
r;�nir raider Of rema*•.=W nr air Una haeJ.of OlPforai• }�yift diagram or ndd"iOnall wall d"alb,
8.For Gmprahe/lll"!•or ansed-1 oap Geothermal Welta having the same. Qt+may use ncc bnek of this page to provide additional well site tfmlh or uwll
wmstntctinn,only 1 GW4 is needed radiate TOTAL NUMBER or-kvrlls CongMWAion details. You may also attach al"fl old pages if ooeessary.
drilied:i.•_ _ s) i
4.3'ntat welt depth below land surface � __(Ft) ?4a• (+or All WO: 3ubtli t this tbrm%vilitin 30 days of ectmpleiion of well
l ar nurlrlplc wvllcli�r allAt:prJu rfdrlfo►rnr(ermnplc-3(n1TilO��m��td�/s}�lir t0(17 I ari mina to the I101101rng:
lk statir,water krorl being top of easing. _ (lt_) Divtgion of VYater Resourexs,lnihrmation Processing Unit,
iJ'ttvrhrr•1i�rJ ivn+Mtiz caonp toe••.'. / d 1617 Mali Service Center,Raleigh.NC276"-1617
I1_%reholediameter: on.) -,(h.Fa 11812111100 WAS h)addition to sending the form 10 the nddr=in 24a
idmve,aLm submit one copy of this form avllhht 30 days of eomPtetJnn of well
12,welt eonstmenon whadt^ u c.gri taclion to the following:
(f t,nuge,mhty w,ble,dircAr lsh,etc.!
Divlslon ofWatter Rcaoifflef%Undcrgl+enad 11*010e COIItral Program,
MR WATER St:PPL 1i W/F.'LL.R ONLY: �J�1f-/�}/- 1 r1311 Niel!3erv(ce c'earar,Raleigh,TIC R7k19-1G16
t le.t/icld(t;pm) C_�V _- Method of lest:�� / P.ic rnrur Sutuely&foieeNon 1Ndt9 !tt addition W"ding the ram fi
the address(es) above, also, submit+one copy of this (oleo aAlhln 30 days of
13h.111I.00fection type: .Arrtotmr. ramptetion of wdl is muuctiun to tht:county hmllh dejtanmem of Inc coil-
vdwe constmew.
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t+non C:t.4•-t North Omnty-Division of w44 Rapourmn � Revi9eet222-2arR
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