GW1-2021-07220_Well Construction - GW1_20211006

11401 H U V 1 1 U ill 1 i C L U tl U (t7 ff—11 for Internal Use Uniy:
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1.Weil Contractor Information: i
14 WATER ZONES
Wa Coniradoripae FROM TO DESCRIPTION
e2 b n° IL '
n
NC W Couiraoinir CertrficwonNnmbw 15:OUTER'CASiNfi(for.multi cased wails:OR LINER afa licahie
FROM TO DIAMET R THICKNESSMAT RIAL
fL g1A n CD c/in 01 g ISCompany Name
1.' J� /_ 1&1 NER CASING OR T,UBING':' eothermalclosed loo
2.Well Construction Permit#: W 2 V O�/j�0 FROM TO DIAMETER I THICKNESS I MATERIAL
Listallapplicab/e welImmvvc#vnperrnils(ie.U/C,Cormty,state,variance,efa) It. IL in.
3.Well Use(check well use): fL fL in.
Water Supply Well: 17.SCREEN ?
FROM TO DIAMETER SLOT SIZE THICKNESS M 1.ATERIAL
3AgriCUItUraI ElMunicipaUPQbife n ft. 11L
Geothermal(Heatrog/Cooling Supply) Wiftidentiai Water Supply(single) n It. in.
lndustrial/CommerCial []Residential Water Supply(shared) 18 GROUT
71lirigatiou FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d fL D f IL 1pmrnp loarm ®rzA
Monitoring Reoavery It. n aiq u� 7r
injection Well: n NN 3
Aquifer Recharge GrotrtdwaYerRemedratron 19 SAND/GRAVE ACK Ifa licable'
uif"Storage and Recovery [39alinityBarrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test []Starmwater Dminage n It.
Experimental Technology [3Subsidence Control n n
RGarthermal(Closed Loop) Tracer 20:DRILLING LOG>attach additional shoots if
Geothermal(Heat n Coolie Return Other lain under Remarks FROM TO DESCRIPTION color,hardnemsoilfror rain ate
nL4 0' 08
4.Date Well(s)Completed: 41 Well ID# R ft-
5a.Well Locati n 105 n op r
5�. T n It.
Facility/Owner Name Facility M9(if applicable) n It. C�
,Vyw P,h�iJ�adce, fed• 1�Ctt�lA/x /l!G Z?7Gt5 It. ft.
PhYsicxipAdddsms�QtN and Zip y� �y It. fl 1P+,�i1C �JRCJaG
DIUL/Kll�i Oyu 16 II 5Q 21.REMARKS
County Parcel Identification No."0 G
5b.Latitude and longitude in degreesfminutes/seconds or decimal degrees.
(if well field,one Wong is sufficient) 22.Certification:
N W J.p&u ,�ibt J 9-1.z
6.is(are)the well(s) rmanent or Tempora4No
SigoatmeofC Contractor, Liam
000" By signing this Juror I hereby ceiW Mat the wells)was(were)constructed in accordance
7.Is this a repair toan existing welL Oyes or witli15ANCACOZCA10gor15ANBACWCAW Well Consbvedonstandardsandlhata
/fffiis is a repair,fill out Known we1/raomhvction iMormafionand exp/isle the nature ofthe cW of this Ord has been provided to the we11 owner.
repair under M remartssecfion or on the back ofMis form
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells Construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land'surface: / 6 J (fQ 24a. For All Wells: Submit this form within 30 days of completion of well
Formulfipfe wells list a//depdrsifdifferent(atample-3@200•and 2@1M construction to the fallowing
ld-
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
ffwaterlevelis above casing,use a+" 1617 Mail Service tenter,Raleigh,NC 27699-1617
1
11.Borehole diameter. (in.) 24b. For Injection Wells: In ad"'on to sending the form to the addles,in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well Construction method: i construction to thefotlowing:
(Le.ar W.rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service tenter,Raleigh,NC 27699-1636
t � ,
13a.Yield(gpm) Method of test: 1 _ 24c. For Water Supply & injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b_Disinfection type: Amount: " OZ completion of well construction in'the county health department of the county
where constructed.