GW1-2022-06671_Well Construction - GW1_20220708

1.Well Contractorinformadon:
j4JWATE1LDONE8°mX s k:•`3wr f,Y.;rl;:•.- �'C:�++i L"''I."�+is5��t;r:aMr n•;v+•
FROM 70 DESCRiPT1IN t r._'_C 5:+.i•5..
W&CoutraetorName
Od
d, , 7 ! d
NC�Wye�UC�onjhaetorCe:tifieajtla�nNumber ;gBg011lEERCASINfi fbir_W6;Fesedwew ORZIIIER a'U to
FROM TO DIAMCM tn. THICKNESS tATFdt1AL
eompwwame b16.'1NttERCASII+ifiORlP[JBIN(i 'eld(&18oir ?:►1t?3kt ie'�ta V•". kxc 'r
2.WeIIConsh7tctionPermit#: 2 /_��S FRoat - 7o 111MME ER TIDc I MATERIAL
Unall appAmble veffeaartrnedon pmults(ba WC County.XW. ft YWMCIe;etea
3.Well Use(checkweli use): R• ft tn.
:47.'SMIEffi4s£i. 3•:hitfX d!;v" ', ?Z;zOSIa lN"�`�A :.•.sY•S.?e�ka?i,'sske ?SC'f J3
waterSupp Well: FROM 70 DiABIUM SMSME I I TEUCHIMS61A78RrAL•
Agdcuiww OMunicipaUPublic in..
Geothermal(lieating/Cooling Supply) .13Residential Water Supply(single) R m 106
IndushWCommer fid Pleddendal Water Supply
!rl&fGROT)T!.•�aktlfF;.�:' .i��f.e".�;?tip':^ 't�i.1� � ' `;ti"iw�i:+�;''.;1 ,�
kd Lion FROM 70 OD@AMODNtr
Non-water supply Well: Q n is
Mordtoring . Recovery n to
Injection well:
R fG
AqultbrReoharge 130mindwaterReatediation t,1y;gANDIIGItAVEGPAQc `_Utibie F' Jt '::.47s':.• !41 a •/ ;Q;;
Aquifer Storage and Recovery OSalinityBarder FROM 110. MATERIAL HNPLACBatRNrMETgOD
AquiferTest 13StotmwaterDrainege. & it:
Expa rental Technology OSubsidence Contml
Cieathemtal(Closed Loop). Tracer ?2cb+D1tII:LfNaLOt O itfathYddittfinolFiKettifri ."'�'•Sf„
Geothenn'aI in Cooling Retam noftr( lain uadei d21 Rammb FROM 70 DFstsuprtorr mta a sowmek ett,
4.Date Wells)Completed:_ /7-Z_Lwe11ID# 3 fL fL 4�
.5a.WeRLocation: t, fL �• '/ ti'
M,OM r/0wnerName _ Faat[IRyIDO.(irappUeable) fL R. o.
^ . J�/ �] p
1 y C.9r/N�i?AT;G R� /�/:11C�rtevy n•G t 2 >2 7V fr.'
P6yaicatAddtess,Cos and Vp JUL• Vb LULL
�'11.tRFMARIt3't"�S?i:`�b::Y•.��'s'A�'' :CE2'ufa�:.'+�:3i`a4'•4r'=Ba'.'t Y.1.f •
County Parcolldentlawdonwo.One
5b.Latitude and longitude bs degrees/minutes/seconds or decimal degreest '
(ifweU field,one lat/long b auffident) 22.Cerdfleationi
q U4.1
6.Is(are)thewell(s)E3Plrn anhnt or Temporary S o Ceni WeUCoatraaarDaW
By s/gnbtg this jomu I hereby too an the nd(s)i% (tvar)tonrbuetad le eeonlanee
7.h this repair to an existing weii: 13Yes or t2NV nldi lS4NGICO2C.O1W or ISt KMC 02C.0200 VOConiftWonStonfi rdsaudttmta
{fthtsisa repah;JJUouthnmm well cW gfi &m-rdAatbeeriprorldedtodo-tl otrner
rapab•under#2l reaurtlasetdon oron thebatkojthlsjomr. 23.Site dingmm or addidonplwell detgb-.
8.For GeoprobeJDPT or Closed,-Loop Geothermal Welis having the same You may use the back of this page to pmvfdo additiomd well site detwis or well
construction,only GW-1 is needed. IndicateTOTALNUNIDERofwells constructiondetells.You may also attach addhic6al pages tfnece= . .
dolled: SMU TTALINSTRUCTION3 ! '
9.Total well depth below land surface: sc a� (R.) yla;For All Weris:' Submit this fomt.withi�30 days'of completion of well
Farmrdtlplensll:llrtaJ/dapths(/'d�Erart(orampfe-B(o)�20j0•and2Ql00� cousbucti0ntpthefollowfng:
io,Staticwaterlevelbelowto ofcasin . _73 +
p g' (M) Division of WaterResource4luformadon Prottessing UWt;
lfwatarianitrabaredwIn&ute•�+� 1617Ma11Serv1wCenter,Raleilp*,NC276991617 '
11.Borehole diameters �a (in.) 24b.For Iniec6on Wel1a: In addition to sending lie foma to the address in'24n
above6 also submit one-copy of ibis fotm'wltitin 30 days of completion,'of well
12.Well construction method: rhl4ehv eoash=don to Who fOUowf w ' J
(ia euga mha -bte,dkectpnsb,eta.) I.
FOR WATERSUPPLYwELLS ONLY: D"ionof WaterResourees)Unde gcoua$Injection ControlProgmm,
�....1636Mal1Serutce Center,Raley NC 27699-1636
13a.Yield(gpm) A`/> Method Of test: 24c,gor Water_Sutm1v et:Inteetton Wens.. addition to sendng the than to
the.addass(es)above, also submit one'cop�of this tbtm wftbin 30 dep of
13b.Disinfection type: Amount:- .� A 2 . completion o well contraction to Who couaty.health.tl...... eet of the.county
whereconhueted.
FOUR GW l' NocthCamiinaDgm=catofEnviromnmtalQuathy-DlvisfonofWaWR=umes.F Revised2dt-2016