GW1-2022-10831_Well Construction - GW1_20221209

koil
�.,r, 7• �?`gy'-�`r.�' �"�y ` z.� - EO(CX�•.:•.
T�J:1LHJ a..�JV.'9S�lJ�b ��N�� 31�4LTs.�►C°" "6'"0� 4��t�� ff'� ' .� ��e�'W
si
L�eil,Confi$ctorlelfoon.
C301L1'Ot1 8�1(1 r,u s ,.
'' # :^•,fir
_ ,"�z.� ' -� .. �#�3a `�� �`w`"�a�t` E' �' ±d 4� 14zWE678B.&ONSS'J UNAIZI
Well CoatmOtorName' x y w n ro iEl z 70s � AESERIPITONt e
4518 Q !_�s c x ^=� a t r76 r"� � .a s �,. � ...tv - s � 2• r
NCWCHbmlu actarGeihfrretronldumber
�'9"`r{z°;� `F� �; ���s ������ ' ',� �1�01)TERC`A$ING ar�iCrmtai�oelCs,�11tL'IItER!d'e • 7e �
A(lus Ordl,inc. e ��+� �sr =FLtOM TO a° ntADRsTESk 4aTffit�h5la MIatERiAT+f i
; . �
��(iS` i E:76tE1VP1ER.Q'AS7NGp2tTOB (': umaFdC3ed S t
_ 2—Well ConstracBon Per6rt4: �, Q d � " ,.rsora zar ,~� tuar,�s� r'rntcrno?sss arnz�ara>;
Lvtal!'aPPtfaa6len�ticw+sbuc4ongam+Lcfi.eUlCComieySmt�l!arfmieGete:Jef z�q"�^t tC ��,it' r> tf Ia �^,� � x �.,, � ", i
3.WPII Use(ehe&weli use)
Water Supply WI. r= 13 SCREL+N ry
,^ # rsom ao altu�ss suorslzs r lstraa�ss tar+l�alnt
Agncal4sai f MnwcipaUpuhlics
Geothermal A W
(Heating/Coo i S Wy) euhai Pates Sepply(swagle)
IndnshWQommercral Restdenhal Uflater 1`shared 1?a1
..; ;,. �PPY,C,,, �) •z18.'.GROIPI � �`
lrti tioa '
• 1K01L: 1AfeY S ,�. TO s: 217A4$RIAL I -•SNRLACBM&NTBHE[HE1� _. .• -.B'AMOIINT."
apply W�
InMnnitoring QiRecovery• :> r ik =1L '
ecBon We1L• - �z
qufferRechmp GIMP- terRemed<ahoa t} F
AquiferStolageandRecog I 79 SAHIDiGRA1rELPedCK.f 6te -
e±Y �Salinity$ainer rxoaa- so ranxgmat >e�rncenuavrm�on
AgtuiefTest �IStonnwaterDramage _
Experimental TaclindoMr Control 't
t Geothemnal(CiosedIooP) �tTracer 10')1t}ILGINGLOG atlacliadditiunsts6eeLaM`" _
Geothermal(Heatiq;/CoalingRetmn). Odrei(axplaiui ndcr#21 Remer7cs)� ,'ixxoxt ro •I nrscalFnON i rwt nraa�
"R.
0 q
4.11$ffWeii(S).Cmrljl]et2d:AVf'ell7D" R s ' 42,
Sa,..Well Location.
ye
Facility/OtWnertlam6 ,FaeilityIDe@fappLcable) ft= jL
�.a^a=*I v
PhysEcatAddresg�tyTaQ: . R"
• Zl�REbIAitIGS u`
Goinrty '� ,, , PmcetIdenhfc2ponNo(PIN) _ - •
Sf�:Latitude amd�lotlgrtade 1u.d�;rees/minbtes/sece_nds oi•-decimal degrees: ,
rt7 atn a
(ifwelt Feld,Ow rs snfiicient) 27.Certification:
tv
6.7.5(are)the lvell(s) Permanent or Temporary
Si 6fCesuS Vetltoatractar Hate
—,by�Jr•s trh ,rclt(:j uvs;-6-—j oouv urlar rn aCcu umlce..
Ills tlnsa repa>r to as enshag veD r Yes or J , . �wt1:15ANCdCOZC OtOU nrlSd v QZC adOD WeII Co�rstm oisStaadardsaa3that a
IJt&isirar au fdlqu 7moxmnrllcvns6iretionrajvmrat+0O'd No 1plalriilteiiritrorDjr&a �PYalthir>rrmdllasheeaprdvldedtothe�veUotivaei
epnfrartderR21 rpuarlsseerioa oroa tliebat pfo&,jbrm x3,Site diagram or additional-Well detorls:
8 ForGeoprolie/D1�1'orQosed-Loop Geoffiermat R'e➢s haying the same . You may use the back,of=tins page to ptnyYde.additional weli site details or well
co"ii6caon,only 1 GW-1,b needed:Iddtcate TOTAI:MLOi5Rof iWeIls coon details Yon may also attach addibionalpages ifneceyy y.
dr f[ed: S S6 BW=— .AL]g!jSPi OC-HOrts
9.Total well de'ptk Mow land suhhie. (fW 24a For:Ali Weds:: Submit,this fora-wid&30 da of
Formulliplex�Jl;lfstalldepths.+Jdf�erm+c,(ewr?;ol�'3@Z00'm+d2@700) constaictiontotficfollowing � c�P�tion of well
2msStatiewaterleve)beI low tapafcasing:. � (M) i)Ivlsionof`1Na#er-Resourees,W6rmadonprocessingUnl4
JJtvaterleuPl is a6aveam r+g uge'+" 161YMati Service Cente'�r;3*eigh,AttV 276991617
]1.)3arebele dFsmeterc Cm.). 24h:For bkogn:MMellsc In addthon.to:sending the fonu to the address in 24a
above;also submit one Copy of this hi-i within 30.days of completion of:well
`12,Well,consfillc#0BnrMoll:. w constructionto the wowing: �
CLe atlt,-rotary.cable directp tar) Division of Water Reso I
' tames,llndl rgroundbjadion ControlPro&am,
FOP.WATER SUPPLY`VM S ONLY e
-1636 Mail'serviee centr_ � � ,,,Raleigb,I+IC23694=1636
IViethod uftest: Water Snatefv&7aieetion Webs 7a addition to sending:fae form,to
13a.lxeld(gpm).. - 'ltte address{es),alioyG,;aLso'sttbmrt one:cppy of Us,form-vrithin 30-days of -
` 13Ii.7Dtsinfection igpe: Amount: constrnction to the-county health deparhnent of the cotmty
comPietion•of well
where consttt rW.
-jo �rotiaaDepaetmceG'ofEtnrimnmenlaiQualify:Divistoaofwateritesoiuees t
-Fotm�-l- ' Y •' . . � RaYI£ed2_32L-20I6