GW1--04049_Well Construction - GW1_20230622

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Feb 1519 05:43p GleatwaterWell Drilling 828 622 7241 p
' E + iSTRtJCTIUtY RE CO 4GM74.l For lntcrnni Uso Only:
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4a:nnnre„Notna 4� it. 1$R C t=NYG OR the i.
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x.1Ve8 Connotation Permit il: �"-nail. To 'Y• . r-. MA
fry all opplfmbte wall cwnrminflanpwtna(Le.1l1H,Caun(y,,4falc.Kri %eta)
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3 WM ITie(chat(well Ilse}: - , 17.4014;tv I
WgtaPSa[►(tlYWeq: roht atarstvx I sitm ns MA78telAL
'•Agricuknrnl Ohifonlelpni Public (?: . h n- in. I
ili Geothermal(IdeatingfCoolingSupply) •11 'elidentiot watt=SupplY(Anglo) ' ."-ft. . ft. W. 1
III IndusltiallCotnmerciai :,U Residential Water:Supply(shared) -&„:our . Iall '
itl olio A : IA UV_,t lail1.^ir.,�i2, . In•
n. A~ t�Tir1 I a
iVnrt t1y'n1RrSnFlllvV►aU= � •
•Monitoring riReaovery' t+. f° I
in)ee on Weil: - p. IR
wafer Routine CifiroundwatorRetnrdtstirtn y91ANna RAVBLPriC.> .•lice.!!~ I
II Aquifer&gr(rpeowl tZeeoVcry ElSniinily Barrier iseom U) i 15i+•:1r, reg,GOIXENTInat
*Aquifer Test 139tttmrwatr:r DAMN __ n- Dr.
*Experimental Tectntology Ogabsideneo Control R" ft.
II Geothermal(Closed Loop) Ofieaeer ill •. WC kW- '. • ,,t,,.,'
•Girotttpnnnt(ffeating/Caoling Return) npoler•(axPtain under 921 Rcmtutcsi. D ie. �1�:.,�.�, • %1 ,
A.hate:Woks)Completed; l s31-well m u tlb it L it' rCr`a, t I ._
,a.Well lineation: AU to ft f iN E I .
lACISA-\\Th k-V), (Cn
Facility:0m Name , Facility IDi1(iftefplletbte) "-
P roll Address,City,and U I , j . .
tr\ 2l- }ARKS
Cimi Parcel IdentificationNo.(P1At) Iilk.:�,�..�:�:I ; e(;; I -
5b.LAtitudn nod longitude In degreealminuteslsecondsordecimal degrees: -- i
Orwell fled,one la/l�j��engin mtRcicnt) , t 22. 'mu /7
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't'!' 4. Mel Weil Calm:tor MO
6.1601r0 the wdl(a) Permanent or ElITemporory
aa..,�� .,. g d sea lbrn,.1 herrlrvor�tlfp Ara Ihr.weir.)WO(WON)MittlnteAd M asoerdaace
i.its fhb A repair to an existing wells riio or No Na/r A.NC-•AC R2C.O1tN1or?SA VC.AC 02C,010PWell Cantfreetin rMattrlowieim'l,hm Ifhle OisarepairAUloluJFnwintw4lennsore+ranUifnrvuato anat2taxpkg.rh..,.n+um,r,he 0 Imrefi recall Ifoelwenpml lathe wellromrr.
r,mIrraterh21 remnr1a solo arna*hocknfiblsfarAl. 23.-Stto diagramoradditlmattweltdintilR9:
&ForGeoprobeMPTorattred-LtfnpGeOlitct'tnalWaltlheVingthesame l�oumas't1O+rtetmetcoTtU page iol>trnvido Additional ttieil damiiseawell
amatnlctian,only I GW t is needed tiiniilnite TOTAL NUMBER or eus Ct)t19Wr11tx1 details. Yblt may 81S0 attach$IkIlttUnal pages if nxssaer):
sigmrricammtvagoos
A TaWt walitdcP,p ryolmvinnd Oprl2l r "' T - 014 yle,.Formvt'sita_ aubnnt this Arm within 20 days of comteletlnn of well
c Per Amin, wellslitrnfiddprlhs regrrear{e mph,-3r,Mtrand:VIM ennsltactionto the li owing:
In.Stalin water-level below top of easing: al Dividoa nt'Woter Mourne.ltiibrmation Pt'oc Ut tg Unit,
1,fwahtrtmrti Isabella cmMgme"." i 1617 M IServiceCenter,tMtd®li,NC37699-16r/
II.Borehole diameter: (9 I Q (in.) / 21{h.1!(rJwlcniitge Wolfs: Ito addition to tending the(bon to the address In DM
�J above,oho submit one copy of this form within 30 days of=planate of weft
12.Wen construction method: Vat `' atnsltttctiatetathefoilttwingr
tie,mac,Witty.table,direct push.et%)
. Division of Water Reaeutees,Underground 1*llon Contra)Program,
(still WATER$EPAi'.11 EX LEi ONLY: 1636 MN Saralee Center,Rintetgb.NC 271;99..i636
13e.Yield Iona , Method of test, PA.el 24e.lips-Water Su*&1(aietitISa Weill: in iedditian to oundtng the(betel to
the address(es) nbotlee also submit ono copy of this form within 30 days of
n3A.Disinfection eype Amount: completion of well construction to the coolly health debmtment of the enemy
where conanaeced,
Moo CW-1 ldorehLSn,olinaDcpnomentafSSnofmnmuastlQuAtily.niriautnai'WNet'tiaHOrutos
Reaiaedz 2:201(t

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Wall Driller SelfLGr uut Certification
OWnen M j New'Well:
Addremc c9S MaStrS ake &pair I .
Permit; -
I$ereby certify that the above referenced well was grouted in appearance in accordance with
all CountlrWail nil
well ram, \OS POnntqlipled,
Cerdficate#: 4151 -A" Ditto G , . .
Construction: Grout
Total Depth: S Type: a.-Infli j,
Casing Type: V G mess: M
Casing DePth: De, : Z(
Dimmer:
Heigh:
Drive Sim
GPIVL' 2b.