GW1-2021-03693_Well Construction - GW1_20210823

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hcrmal(Noting/Cooling Supply) �Restdaltiai Water Supply(xingarq R td. io
%I4aIjCc)mmeroiai Residential VliaterSupply(shared)
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'1 nter inppl_v Wdl:
itntin 1lecovery p. ft.
an Will:fer Iteehatoc Dcratindwater Remediatinnfcr Storage and Roeavery asmunity Barrier tAt1Id1GRd VBt PA H&TJW �rcr Teg tororwater Drainagerimental Teetntalagyr f ISuksidcnce Control f. k
barmal(Closed Lnop) 13TCAeer W t)R11.14ttcn»al Heatin oolin Reatm) Barber(ell loin under621 Rcmarks) ft. ro R =
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fib.Latitude and langitude in degraesimimotes/seconds or decimal drgrc(,.s; �,3Llo rJgCt".0
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,� !?t+nymmn 001r.;irm,!hm4r P cw11f m tha!the UVA(,)tarn(wmal rrrerdrm Div!to orrnntrtee
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f•,rtbls i+a r rife, €J Autd�tnxm and€.mnwrncrrnn UrjermethMm�rl crprain llrc rxvnn,•oreha ••np)r afthis rveord bar l emproU0 f to the welt mwler.
"Pair ramdar Ali mcrrmn*Vxrft fir entire tract Aftittajmmn.
23.Site dimgr m or additional well details;
R Car c prot+eiOlYl or t3aaed-l.nap Geothermal Welimt having the saute ')'*It may use the back of this page to provide additional well site dmilt or will
unnslt.dctinn,anb.I CTVd•t is needed. felttfoate TOTAL NUMBER ttrwclls c.orlmtrirAian details. You may also attach additional pages if naec9gW
?:3 Deal well dcptA below land surface:
J�arntaP��ratrxerrtrsr,rrlte�ria•�,rtpernu ferraAp�r.s�lrrkr.,,nrr�laA,q --(R't 2'R►. Irar AIt WwIa: Submit this form within 30 da3s of eampltdian of tvrtl
eamintmion to the ibitolving:
I(1.3tatir,watrrlrvcl t►einsr tap nfcasings Divietoo of Water Rswurce&lafhrdnation Processing Unit,
Ifny,rem•IGaT»r(,r,mtuiarcasingt(Ar�"•t� Ib17h'l'atll `�lceCt!ster,Raletgh,AlG`a71►99-16I7
il_tlnrehntrdiaalctcr;- tic [ (in,)
24h.For Injectille Ia addition to tending the form to the:Achim hi 24a
I z Well construction method; : n t?OM also submit one cagy Of this form tt Ihin 30 days of comp€dint of wrtl
(i C.mete•,mealy.F,blc,dire,c ptisG,ac.) amsbuction to the following:
R WATT,GR St:PPt v VtlFI..LS ONt,Y; Divlslon of Water Rtaltmv.Underground injettioo Cots"Progrnm,
16M!Nail Service Cenni,RAlc gt,NC:1709 636
13a.Yield(gpm) - Meow of teat; ` 14ce Ivor Allifer poi &FAketlon W lW, In addition to suading th !bu e m to
sari.Dlsinfec"on t the address(cs) above, also submit ode copy of this fools artthim 30 dayw of
ype:..�.._. ._, wmt►tmr W � completion of well catn5vactica to the conrily hmalth depnnrnrnt of ilit:txnlnly
vTtmrc txaastmcrad, !
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h'Mh CSutatran t>etamm�ant,af I?nirttnrn,mtnt gmtttey-faivrxrtan tat'tVsrct ttaytmrc�
-- R-f dt222-2a16

Well Driller Self-Grout Certification
Owner Pad D 141,ff,( New Well: tl
Address: u n , P.ltU->0,n a fair:
Permit:
I hereby certify that the above referenced well was grouted m appearance in accordance with
A County Well rules.
' �-�Well Dr ler: k�ec Me.0 cicuos `_--_
Certificate#: Q U:I --A Date Grouted: (X, Z-!
Construction: Grout
Total Depth: U Q 5 Tne:
Casing Type:—QVC� _ Thi ess: lit to-X-d
Casing Depth: Q U Depth: 2-D
Diameter: LQ
Weight/Thick
Height:
Drive Shoe:
GPM: 4