GW1-2021-04245_Well Construction - GW1_20210419

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Pint Form
WELL CONSTRUCTION RECORD f 11 For Internal Use ODIy
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L well Construction Permit#: W P 2b 1Z `d OM 'no �m
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3.Well Use(cheek well use): IL fL tut
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FROM TO D1A IEM storm ,. .T�..
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Geothermal(H atiag/Cooling Supply) 56sidwdel Water Supply(single) fL. % IL
1ndusttialMmamemial DResidential Water Supply(shared)
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quiferTest [)StmmwaterDrainage
mental Technology [3SubsidenceControl fL tLeothermei(ClosedLoop) Tmcer 20.DBII.LiNGLOG ettschnddidauatebeeatfeothermal(HeldnSIC001ing Remm�) ..Other( lain under#21 Remarlm ]FROM 4O DESCrtIPttON
aft. l A R' r e. G 4
4.Date Well(s)Completed: j-� Well In# r b � $" rL c,�e Su Ce ' 1.
5n.lVeil Location: fw a R• Esc a+v
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Fa llitylOwnerName 'hoftIDH(ifgptWbte) ft R
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county Patrel Idemificedou Na(PRO
Sh.Latitude and longitude io degreadminutealseeonds or decimal degrees:
(ifwell field.one lWi ng is saffiefeat) 22. [cation:
6.Is(are)the wdi(s a umueut or Temporary signature of ,wen haetdr Date
�!9(�AT By sfVft dds,four,I herby cm&dw die weft)seas 6mo conmovd in aoaardwce
7.Is this a repair to an existing well: Dyes; or �.rNo rrtth ISA NCAC 02C.0/00 op lSANCAC 02C.0200 WellConovedonSo datOw d that o
Vd*lrarepolr.,/Wawkrmmwellce;unaclPonMformadorrartdaphlin'dw wairegfdm copy efddsrecodhas bow proWdadtodmsrrNmrnep.
rrpalrw de•#21 nmurkswdon op an the hn*4f*1rform. 23.Site diagram or additional well details
8.For GeoprobeMPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to ptuvide additional well site details or well
construction,only LOW-1 is needed. Indicate TOTAL NUMBER oflvells construction details. You may also attach additional pages ifneeemmy. .
drilled SUBMTAL 11ySTR LT UCTION3
9.Total well depth below land saftec; a S (ft:) 24a.For All Wells: Submit this form within 30 days of completion of wall
r-nmhlplesralk11valldapga fdgterere(r noe-3@200•mrd2@I001 construction to die following:
10.Static water level below top of easing: , (lL} Division of Water Resources,information Processing Unit;
ffanrerlm'ells aboreaarl»&ara•_" 1617 Mail Service Center,Raleigh,NC 276991617
ii.Borehole diameter: (in.) 24b.For Iniection Weiss: In addition to sending the form to the address in 24a
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above.also submit one copy of this ftmu within 30 days of completion of well
12.Well construction method: f-CA-10r l l n Sager:-toy.c Wt.daeetpush.ore.)
TA• construction to the following:
fi
Division of Water Resources,Underground Injection Central Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centci•Raleigh,NC 27699-1636
13a.Yield(gpm) �-� Method of test: L pk �'"' 24a For Water Snunly it Iniectioa�ells: In addition to sending the fmm to
the atdmss(es) above, also submit one copy of this farm within 30 days of
.13b.Dislnteetion type: h I�1 7 ¢ Amoant: /Z completion of welt construction to the county health department of the county
where constructed.
FamGW-1 Me*CmftDepamaentoflimmnmeatalQuality-Division aMlwerit—am Rsvind2, -WH