WI0100592_Geothermal Well Construction Record (GW1)_20201112

1^. Wish� Contractor
J 0.Ml�ra� G'st 1 C (5 Dr?,
Well Cormonar Name
4093 - R �ItGr� AR
NC Well Connector Certification Number
.� �yr.a: pcl �nGAShG�iIPR�aL
Company Name
2. Wall Com[racdon Permit d: w l o )Q a
List all appiksoNe xxll wasma Rlnn rem,@ll.e. OIC. Cannp', Seem Yatlonm, etc.)
3. Well Use polank well use):
DMuniormInPublic
Residential Water Supply(Engle)
QResidential Water Supply (shared)
Storage and Recovery Lj Salinity Bearer
Test QStormwater Dmirlege
(Closed Unit)
4. Date Wdl(s) Completed: I1- I2- ZO Wall IDN
So. Wall Loradonr
UDmesjR°'hche Ready
Feeil! a/Owner Name nadirs lDa(da"licable)
lay St.xa+ Fern plrkt, riv flsl.evdle
Physical Access, Cia, and zip 'I iBeoy
By r\cnm 6 In
County Pascal Identification No (PIN)
St. Latitude and lon®lude in ae®aeal JwWslseconds or decimal degrees:
NRS
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nec'mvler Rl nmurk, ewvl^a "ran IAe hunk njlldsf-m.
e3. StiY diagram or edNllonm well details:
8. For GeopmelW11)"ar Ckewd-Loop GeoBmrmal Wells hav
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You may use the back of this page to provide additional well site details or well
condonation, only l GW-I isneeded. indicate TOTALyp�R II
constmetimmdamils, YoumetyaleoaDachedditionalpagesifnecesduty
drilled: rJ n^ �{+77y�((�• nn O
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SDRMMALMSTRUMONC
9. Total wall depth below lend surtace: IY O f % O aw,a All We ; Submit this to= within 30 days of completion of well
Irarmulerple rolls N(allderlla efdp(eronlermmrle-3@200'aM?Atl) _s\�'sae
10.Static water level below top oP easing: \00 BfaFul
pwry lewlle
onstmmion to the following:
DlWeion of Water Remurca, InPormetlon Procazsing UNq
aGo,xttu'Iryp. m�e" I�1 Q
1619 Mall Semba Center, Ralsigh,NC 29699-1617
11. Borehole dieme6n'--" (in.)
24b. For Injection Wells, In addition to sending the form to Me address in 24a
12. Well cor:sRvelio" seefind: IM1C 0. rlA
above, also submit one copy of this form within 30 days of completion of well
a e... , many, cable, oirem push.anal
COmtmdion to the following,
Divieion Oro f Water Resources, Undergund Injection Control Program,
FOR WATER SUPPLY WELLS ONLY.
106 Mall Service Center, Satellite, NC 27699-1636
1". Yield (gpm) Method of teats
24c. Far Water Sanely as pdeetlon Wells: In addition to sending the form m
the address(es) above, also submit one copy of this form within 30 days of
13b, Disinfection Ii Amounts
correlation of Well construction to the county health department of the county
where conducted.
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