GW1-2021-03845_Well Construction - GW1_20210823

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pp/irn.4lr teiJntnrrnicrinn porrngx(l c(II(.;( �nnnry,dYal�Variance,arc J N. "A tfE.RIAL
Z•Well li3e(ehtch well use}:
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Agricultural owunicipoUPuhfic FROM TO ntA14167Ctt a THICKNESS MA71MAL
Geathrnttal(19cating/CorAfng 3uppiy} �ReSidential Water Supply(single} 0 R.
Industrial/CommercialResidentfal Water Supply(shared) tL fi. �.
frtt otion 18.GROUfi
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h4onitorinB n" 7el tk, COxe-/t Wi%tax
injection Well: Recovery 0. fr.
Aqnifer Recharge ElCroundwater Rcrnediatinn ft. R.
Aquifar Storage and Recovery Salinity Bamiet ' 19.SAN11/GRAVEL PACK
AquiferTeit nt To A L IIttrtwClrMxlKltttteTtton
0StnrmweterDrainW rL D.
Utperimenta)Teelmology JJSubsidenee Control
Geothermal(Closed Loop) T^iTcnecr R"
Geothermal(ticatin Coolin Retum) Other ex in under p21 Rcmaft) Rf11i.T LOC tttpae6 td neeretm
PROH To D Color. raft t Lit IA rirg sae
¢yam f fr. 1-aft. )4— t �'I.Rate 11'eN(s)Cntnpicted: c� B Weli INI zz fr. ` f_ / �K<
Su.Well iArRIton: ( ft Fyn ft-
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21.REMARt(.S
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Portal identification Na.{P[lv3 ,t ilw,•�€• ;'�.3''
�h,i+AtitlldC ROd 10112ittlde in degreeslminateslseeondsortieeiMilI degree-: _
(it wolf fichl,one lnt%lig is sufiieicn1i o ! ��,Certirica6nn:
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A.Is{arc)the well(S) Pcrmonant or ©ITempnrpry
Si (olurc ar Gerlirica Weil Contractor Dise
"$ming rHre.(orm,I heml!v retrlfy ram thr.Aw•!!(xj avrr rxerr'J eemrrmrsud to atcmrdor+ce
?,is this A repair to an Ct:isdRg vve11: OXrs Or Q1V0 p411,i5A.W-Ar..`021:.?tM)nr 13A N(.AC.NC:tt200 Weft Gr,eslrnetr ur SYarrdarde mrrt+Am.r
f,/'tl,fr is a repair.fry mu lmnwn nvdl aunxtrnarnn L�hrmatlan a?iAjffnrrt/hu anrore gr1hu tapl�of rltre r�'/v/NI AOR bra pMlddeYf rri the W1f mutter.
rraair under 01 remarkr.1cr lml or on lire hark nflNOOM,. 23.Site tliagl tom or addltionRl wrap dtdglls:
11011 may use the tack of this page to provide additil well site derails or well
R.Mir Genprahe(11PT or Oused-i.onP Geothermal Wells having the same constntcfion&Mails. You may also a ilach!additimal pages if Aceemani.
mnslnrcticm,onlh I C1%14 is needed. fndicato TOTAL NUMBER of urils
drillMi___ (� I A,rrrAt 1 'cl R IM. ONS
?.Total well depth below land surface: _(44 M. Bor A�. I!Wails: ".submit this form srithin 30 days of Completion of swell
i�r nrrd/iprc xKl7.c fitr nli drptlrs.f`Iljfcrrnr(etnmplc-3[n�.T00•mtd�ii I001 consltttctian 10 the f0ll0lcing:
IA.3tstie water level below top of casing: �® (R•) Division of Water Renturees,Information Processing Uldy
FJ'walerh=llsahnaecasing.me"• (� 1617MitilfiesviceCenter-,Raleigh,NC2709-16117
1 T_Borehole diameter. �_° (in.) UK For falecti2p_W_ellx In addition to aending,the form to the Adores in 24A
alcove,also submit One copy of this form within 30 Clays of completion of well
i Z Well constniedon method: constntetion to the following
(i c,anac,rottr)t.cable,direr&Push,etc.)
Division ofWater Reaonrces,Undetrgr+ound ittjectfon Control Program,
MR WATER St:PPI.Ir Vill ONLY: 1636 Mail Service Center,RRlelglt;NC 276994636
P_in r{.%1 ..- .. .. /--a.Ca:.,..M bMIITO 1hr roan to

Well Driller Self-Grout Certification
6
Owner: N w Well: t�
Address U-14 -O-rm
--�r— Re
P!em*: 71n2t Leyl L-L-q e tcqos,
I hereby certify that the above referenced well was grouted m appearance m accordance with
all County Well rules.
Well DnUer: )®S;K D f\J Signed:
Certificate#: L0--6`1 -A Date Grouted:
Construction: Grout:
Total Depth: 2-q Types !"
Casing Type: SA'-e-e I mdaiess:
Casing Depth: -21-- Dept: 'Ia�
Diameter:
Weight/Thick-
Height:
Drive Shoe:
GPM: TD