GW1-2023-02118_Well Construction - GW1_20230303

I� V4TUL tL I--STRUCTION RECORD(Q -1) For lntem 'Use Only: -
! 1.Well Contractor Formation:
WeliConnactorName FRONT EO DESCRWnON
.� FL 3
ZG� ?,7t3 7 r+
NG1Vet1 CantrjactorCecftflcaFioeNomber -15,OUTRCAMNG(forTzdd-casedrveiis OR1C,Pt rfa titabl
dv(a GI ise��I �f lI 6'�d} rlR,oar /To/ nrkt+mxaR TffiDct�trss tvT>xu
Company Name 1 T fn (�I v 11
yy4� �(}/ 16.I1MRCA,MNGORTUDING.f eathermatdwed-loo )
Z.Well Construction PerHdt#:I 1 D >�Rols� �o', nr�x T�ctavEss as�tosr
Ust all cwpllcable well construction permits(i.e.ENC.Count};Star4 parlance;etc.) ft. in.
3.Well Use(chedtweR:use): M I ft.
Water,Supply Well: 11 SCREE1 I
FROM To MAML•TER SLOTS= THSQQVESS MATER
•[gricuitural cipal/Public is
Geothermal(Heating/Cooling Supply) M ential W ft. ft.
Supply(single) ft ft. in
• Industrial/Commercial DResidential Water Supply(sbaled) I8.6R1)I)T I .
' IlrigatIOn LtRftRC T10'. MATSUAL EMPLACEMENTM MOD&Ah1
pion-WaterSupply Well: G ZO �ft' t /TC f OG
Moniturmg 0Recovery
Injection Well:
Aquifer Recharge E30roundwaterRemediation
39 SANDIGIAVELPACK-Ma Ucable
—Atlubfer5torageandRecovery �ISalinityliaaier aROM TO I MATMTAr. En�Pt actnm�TM1rETapz
AquiferTest 0&ormwatErDrautage ft. I ff.
I 1 —Experimental Technology DSubsidence Control ft ft
Geothennal(Closed Loop) UTracer 20.DRFLLINGLOGiaffaehadditionalsheetsifnecessars
—Geothermal(ReatingJCcolingRetam) — Other(explainvnderMlRemom FROMro: nEseStPT[oN[rntar,haraacss soatmcrtt a otaiasue
12-8K-Z z 0 it.
ft SZ Art s�
4.IDate Wells)Completed: Well TA# 5-Z n• 3,bv it
I
i I Sa.Wel1F.Ocation:
�;� Ralah sM►�h -
EacilitylownerNiamc FacititylD#(ifappliaable)
lay Pock(VAV P6,A We3-lTeffrp�;n,. Z8G9y ff ft: tit.. a•rL a 'ry ii A
nn
Pirysicai Address,City,and zip tY_ I it ` MAR
L�31IZq �1.R Rs
County I ![r;C•ie;;. -.�� �i: '. •ry l�t:i
ParcelldentrfrcationNo.(PIN)
^ 5br.Latitude and longitude in degrees/minutes/seconds or decimal degrees: II .
1 (IEwcn Sc[d_,g{r,E�at/tong is sumcient) .CertT'�I[;ati0
T
f
6.ls(are)the well(s) ermanent: or Temporary signanazofcer I6ed�velt naetor Dare
i -
j By,slgning this farm,I hereby certify that Ilia u�ell(s)was(were)constnieted in acc
7.Is this a repair to an existingwell: DYes or SIN'. tivith I5-hNC.1C¢vC-0100 or ISANCAC 02C.02001Ye11 Cornutrct[on Standards ar.
Ifth[s isa renalr,fdl out kttnwn well construcliminformation and explain the narms oftka, wpy0fthi€rec hasbeeaprav!ded to theweltowner.
j i I repair•under Q21 remarks section or on ilia back oftWorm 23.Site diagrt or additional well details:
S.For Geoprobe/M or Closed-Loop Geothermal Wells having the same You may use a back of this page to provide additional well site details
I, construction,only I GW'-1 is needed. Indicate TOTAL NUMBER ofweIIs construction de You may also attach additional pages iinecessazy
driIIed: SUBMITTALiN6TRUCTIOPIS
` I
II g_Total well depth below land surfacer 24a.For All Ways: Submit this forte vri2hin 30 days of completion
jI1 Formuftiple:vellstistalldepthsifdifferent(example-3@200'and2la�Z001 eonsttnotlonto hefbIlowing:
10.St .fla water level below to of eas' a,
P �' (fit) Division of Water Resources,ldormation Processing i•Init;
Ijrsater level is above casing,use f i!6117 Mall Service Center,Raleigh,RAC 276994617
j I 11.BorehoIe diameter: �� (in) �4b.For Injection Wells: In addition to sending the form-to the address
above,also saf1mit-one copy of this form within 30 days of completion
! 12.WeIloonstracoonmethod: iv r- constmcdon efollowin�
i (s.e.auger mta:y,cable,disectpush,arc.) - � '
➢ivision of Mater Resources,Underground Nection Control Progr
FOR WATER.SI7PPLY WRFC 0.MYc 1i 6 Mail Service Center,Raleigh,NC 276991,636
13a.Meld(gpm) V rllietltod of tes -fi t �I�T e.For Water Snpnly&Injection Wells: 7n addition to sending the:
the address(es) above, also submit one copy of this form vIdthitt 30 c
13h.Disinfeetion type: Amount: completion of 1 vall.construction to the coutrty health department of the
1 where co0stiac
1