GW1-2023-01756_Well Construction - GW1_20230223

L1-G CONSMUCTION REGARD MR-I
JI For Internal Use Only: ;
I.Well Contractor Information:
Yyl S. (� � I&WATE#DNES f I
NC1i ConuactorNamc QR f' TO DESF�iFFIUN
LI0013- � 1low
NOvetlConlracmrceft cat;nni<tamher V OUTIM CASQtoi(ermoW We%)GRLINMc+� i
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Company Name +�•�� ft: ti. in.
16.MEItCAMGOR t?`ltBING(cothermatclo6ed.IGOP)
.w�E�>tsttuc6oll hermit s: W 10 94 PSt)3i I To nrh%lea lgact( HnT RUL
List u1l a{tptiri►Flle Heil cansiluction pefmits(i e.FIIC,Cvtady.gate.t'ariaare,etc.) .0 f t• f �a �• Zr'a' Pve�
IWell Use(ehecil well Use): ft. ft: ht.
Water Snpply WeU: 17.3cRM
Agrirulmrat D oniCipal/Public EaO�Zf. TO ft, D&1hi8rER SLOT SIZB TSIC[a1TP5S AUTHJUAr
Geothermal(lieatinglCmUng SbPPIY) "` Rcsid=dd Watcr3g%y(age)
it; ft_ in.
Iodustrial/ColnmerelaI DResldentialWater Supply(6awd) ,ggO
UT
IErI gtlof! i:ROSi I TO NIATERMI, �►1pI A O+-��hiETRODdc,L1fOGNf
Non-Water gap*Well: 6 � �0 �• QQ}gYit�.e G t,t l�
Moaltorin-q E211ecovety g,
[AquircrTcst
ion Well: i
iferRechar a
S �GranadcvaterRcmcdiation
iFerStarnge and Recovcry r�ISaliaityBatricr � Heal
�R031f TO ItA'CCQFA FhfPL4CEiiF4TEIErHOB
BiStollnwatcrlhainae � �.erimental Technology 0Subsidence Control ft: ft.tberinal(Closed LOOPI DTmccrthctmal(Heatin lCooUn Rctuatt} Clbcr(ex 3ainundertl2lltemarks) o>`t To DL5t�tlPTlo1llrmtarlratdneusanrmrk
ft, C,� Q t.�-btatrG(Qr
4.Date Wel(s)Completed,: 2- - 2 3 Wets IDp f r: S'a•
5a.Well tiOCatIODt $• ti
A!Mbtrlvr Cnik-/lA rk
fnctlitylOwnerName FaaTtymg(fopplicable) ft ft s ;L 16—- El-
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V!S' a tae.o, L�� n: F. F t i3 ' l
PhysiedAddrew,Cityraud2ip ft R
^A Uri!l
33
County ParcelIden6ffC =xQ.(PIIN`)
Sb.I,atitudeand langitudein degreesluusmteslseconds ordeeimai degrees:
(if%veil Geld,one NVIong is sufficient)
?Z CeFtIIlCatiOn:
35. 3gt 1.3'IsSyU" N �I' S1' �1.5sr2 t" W
Us(are)the well(s) 6' =ent or Temporary lgtmlu re.01Cc9ifiedlYoUConuactor Bye
� B_v signblg IW fono,I hereby certify Thal the UZU(s)tiros revere)conuracred in accardonre T Is this a repair to as existing west: DYes or 09, uvh ISA NCAC 02C.01W or 15ANCAC p2e.OZ00%11 CCWj',QCrlan Standards and rhar a
If rlds it a reperr.Jilt out known a.011 eanrlruelioa rcjor,aarlon and erprQin the unrar- vj-zfte copy ofdj&recordhas Seen proerded rn r&e meH orcner_
repairunderW remarkrserdanaroniheba&afrhbjom. ,5
agram ar rtdditioaat aveil dc4ails/
9—For CenproltdDPT or E'.losed.T.00p Geom v.,nt Woo l mving the a=c YOn%nag Use ther back Of this page to provide additional welt size dom1b or wcA
Lvnsuuerlon,only I CW-1 tp=ded.indjwWTOFALxUhIWMQrvrens m"EMeGaadaulls.3Caumayalsaatmrhaddiuoenlpagocifbeeraasy.
drilled: SURIbii7"Thi_7tNC!'ltTl("t'IE1iVC
9.Total►veil depth below land:surfacw
Formalripleicetlsiirratfdepthsi1dijjerenc(emmgle 3Ca2pQ'and2�a iQQ`� f } 24a`FO!All WpuSl Stlbmit this form within 30 days of completion of well
cansiruction tothe following:
Ill.Static writer level below top of using: t/C7 (ft.) Division of 4yaberltesourees,Informatioa Prne tf%raterlerrlis above casing.use"f" 1617ANIServiceCenter,Italelgh,NC27699 617
ILBoreholediameter: G• Z (ta.) 24b.For Inlection Welts:'16 addition to sending the form to the address in 24a
1'.Well consireeflon method: abg'et also submit nnc copy of rills Jolla tvitIlin 3U days of Completion of well
(t.c.aeger.muay,cable,awtpaal,m) ------- COMMegontoftmouft,
FOR WATER SUPPLY Wiff"ONLY: Division of Water ResoIMres,Undeagreund lnjet:tion eontmi prop.ram,
1636ikMSel'y MCeRMP,Raleigh,NC27®9 I636
132.YkId(0m) °Z Method of test; 9 a 1. Ce nVCti ntR Mr.For Aft 5nn1 I ItI 'en�ITe c; In addition to senrbg the form to
13b.Disinfection type: C'.h 1 o r; to I�mo�� 3 .}�bS Ule addresS(es) above,alSO submit one copy of this form within 30 days of
___ completion nfwell ennctrlic6ne tr..t,,