GW1-2021-00376_Well Construction - GW1_20211228

WILL CONSTRUCHON RBCORD torImm-nttiecoley-
This form can be used for single or murtipre wells
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'NC'4Srslf GoiiSractar CerlificationNutriber
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Comparry Name
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17Geothermal(14tatinglCooling Supply) JVesidential Water Supply(single) Ia
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&'Z;ItOUT
❑Irri on FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
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Non-Water Supply Well: fL (L
QMoniwng ORecovery
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FROM TO QD
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❑Aquifer Test OStormwater Drainage
OExperimental Technology ❑Subsidence Control
20.DRILL ING'LOG attach additional sheets:lf necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRTMON color,hardness,solUraek tyM gmin size,etc.
LlGeDlimumal eatin m i ®Rc�m) COther ainunder 21 Remarks) IL $
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Facility/Owner Named Facility lDlb(ifapplicable) so
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410Phsy�sical Address City,and Zip
County Pawd Identificz6onNo.(M) C 2 8
5b%Lat@ttrde and Longitude is dt srm uOWseca ds or deal>ml dkgFawa�� -
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Signawre of Certified Well Contractor Date
6.1s(are)the well(&):_Wermanent or ❑Temporary By stgning this form,I hereby certt&that the well(s)was(were)constructed in accordance
7 IS thi4 a n to an existing with ISA NCAC 02C_0I00 or IS_4 NCAC 02C.0200 Well Construction Smuxkurls and that a
repair listing well: Oyes or o copy OAds record Ins bemp mukd to the hell owns
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raRav MAT 921 reazzris sadbw or as the A=kgJAAarfMm. ZL 9k dbgr=or addilianA well debi0m
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For atullip/e injection a ruam-iratersupply ive/1s ONLY wilh the same Wgm vc&am)vu can
whin t one fmm. S FRAUTTAL INSTUCTIONS
9.Total well depth below land surface: �® / T (ft.) 24n. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list aff depths ifdi,B'mw(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:. t{I �� (ft.) Division of Water Resources,Information Processing Unit,
Ifmater level is abore cwhs&use"+' 1617 Marl Service Center,Raleigh,NC 27699-1617
It.Borehole diameter._ (ia.) 24h.For Infection Wells ONLY: In adddm to sending the form to the address in
34aahwvv also submit a copy of;dtis faratr wiffim 30 dam of campkbon of vmff
12.WeA:roust"n6sa methadt canstruchm to the fnllownng
(ie.auger,rotary,cable,directpush,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield �m �y 24c.For Water Supply&Injection°Wells:� _ Method of �.4(�4• f cif
Also submit one copy of this form within 30 days of completion of
13h.Disinfection type: Amount: f o Z. well construction to the county health department of the county ufiele
ff�mml -ll APomglaCaeor� of mmd —9Dna�mo D sR Reviscd Ampro 2013

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