GW1--03275_Well Construction - GW1_20230511

WELL COMTRUCTION RECORD(GW--n 1Forin(cmlilthDOt1kY
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i IGautezat infonaatt¢n: ___
rS t4.WA IANPS FROM TO , nesmurnos
Weil Coo,worNom
Ccfl1jLiL
V K.' t OUTER TO 1 `, 7 4 ^4'CempanyNnnae _ l j P\iCI
tQ litNtilt 4ls 71f>Ilr'il.�Oilwewl c-F�'_,_,�`1 � ur►tt�Aw
2.Well Construction brit t:Z02 ,- Z_S�S'Cl-t?ion Inkoi 6. To it. ntfufr In.. cs�*°
tortaH oyplloabfa Iva ennurralor patpt0s(l o,U)IG Cmaxy,StaWr,itotance.eta)
R: fr. in.
3.Well Ilse(cheek wee use): '
Wster.SepplyWell: tart TO HIAMtOnt IEW/Rnan I
r4tCrxe= MaTeidal.
A�riCn{tltral unia'ind/Public (1 B. a ' I
Geothermal(ticsaing/Cceding iY) esideotiot WaterSupply(single) 11: it. in. ,
industrial:commercial Residential Water Suppiy(shared) wA>rlornrr.
Irrigation - f,8 Gd0it1 00 n tc . '¢tut��a G'�
Non-Water Suppiy WO': Mft.
Mottitttring °RtxotrorY t'' Y`
njeetioa Well: ft. R. '
GroundwataRcn►cdistiun _._ g11 tea
Ttedwtgc 19 SAM/GRAVELPACK ifa=e)
gaifarStorago and Recovery a(�ludinity Barrier tRRD11I ri, n.
Aquifer Test DSmrmwaterDrainage
Eniserimental TeelmoM@y QSubside►lco Control rt. rt.
Geothermal(closed Loop) Mica 'GDxRILLINGLOGentac ..,, ,•: .r: r . I. roae,r+++�•o)
TO
Geothermal(Hr>tAing o t l in Cheer(caplets tm8at q21 Remarks) I tt, p ft. '�`� 1 i1C l .,....'
A_tints WeiRs)Completed:3—1(0 a3 Wcll IDU _ V k. T I' .'"
5a.Well I.acunaa: ft.
i enkq Forest- Sehprr LLC L. 1• �' t'
l�dlii3aIntnaNama . �}-E* S Facility Wit(ifapplicaltta) n' L�j• r' Ems'i v -r'h
• I rorS 6 n R. mAY 1 2021
p,Visni Address,My,and Mp 21.f�SMARItS
,iacl�stn �5(�3 ...—3% irltor.'r,,;,44.1ari P« r4 Un
County Passel Ideatillestion Mo.(PIN) eteeCtilaCtiv
RI).Latitude and Iong)tadt in dcgreerlmimlteslsseeeconds or decimal degrees:
(r035aCt 3 rwen flat,ace tatilool;la IN ��` ne
U t . J � W 2 re No
v-(`1 - Z3
6.Watt)tee vttdl(I) crmenaN or ©i emeelltr' 1tarfCerdlial Well Carhsatar Dale
9 liy almnas!!Ions farm.I hereby wags that the wall(')was{kov)connected as accordance
7.Is ibis a repair-to anesirdogWar E3Yes or 74No sob IS.itiCAC:d2C.0100orLIANCACWC.01tlD Well Cotalenerion.Manclards cwt.dam a
!ftliais0mail:.JIM oakum mil ea:suucum ilearrsattoe• ' gain the MUSS ofthy taPPofJrts Iwo ad Mayen MOM'to dig:MI nivffer
nix*undue A21!markt t Mot oronthe hack of thisfant. 23_Site Annum or aadlttonal well deeds
S.For Gcopmtatt;(mPT or Qnt llrnopGeothermal Web having the some You may user the back of thin page to provide additional well site death ar well
miashnlet)an only I GW-I is needed. fediceto TOTAL NUMBER(Swells CohstrIucti on&flails. Yea may also Reach additional pages ifaoet.ssary.
drilled: (`��jUlft1�7'1 wT,iNrRiJCTroNS
'�.Telat wail depth below hod Statue: �/`� (0.) 24a.prat AN W,ellr: Whit this form within 30 d>lys of completion of well
tm.uaripfc verds list rm fcarim m fewrut ia-3(4 'O xiaafi 4'+ construction to Mc folluoiag:
•
1R.Static wider level below tap elusion: •• _ W.) Division at Water Rearureee.Information Precession Unit,
0+2114'fowl Is(km tttsing vie".'•n l nX 1617 Maio Service Center,Raleigh,NC 27 04617
f i. L X Roreboie diameter: I V (In.) - 24b.Far ttafernow Wens: To addition to se�nding the form to Ike address in 24a
l.L/� alcove,also submit one copy of this farm wIthld 3tl days of CWapt141trm of welt
!1.Well construction method: YV f l 1VI 1 construction to the follcmiti ,
(i c.sum wart cable.direct push.nu)
Division o[Wtiter Reaoal'aci.IlndCf found Tlljattoa Chitral Program
aaW.
FOR WATER SEpPLV WELLS ONLY: 1u36 Mall Service Cc nter,Rigel"NC 27694636
13a.Yield(gum) u/ Method or tesir 1 b itddroWater ill, Infection dove, Woo bmione coy tiffs to Gam within 30 days(If
Amman - . i completion of well constnxdon to the comity health deptaanent of tom county
fah.Disinfection type: -• where constrained.
'IlonaOWI Noah Ce enaDapurtmcntoflimdroetcatta1Quality•DiviscmofWmn.Ilaseenes ' Revined2-22-2016
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