WI0100444_Geothermal Well Construction record (GW1)_20160811

This form can ne raw R" t a" w -
1. Well Contractor Information:
inch PlAmmons
wall CoalraowrNantc
41 37-A
NC Well Conne" CeRificattonNumber
Clearwater Well ❑tilling
IECEIVED
Ion of Water Resources
fori [3se oNUy.
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TO
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441182
Water Ouality Tlegiona€ Operations 'ru n mea A
- PisLaville €3r2_g4is"t:Wb, AQ ft. in,
CompsayName DI v Lam] ` � �
', Well Construction Permit l
List all applicable wolfpermtts 0.e. Cartn[Y Stare Yariauce, TitJecrintr, rraJ
3, Well Use (check well use):
W"Wr 1aMtmicipaifPublie
DA cultural
f rotharm&I (14eatinglCooling Supply) ❑Rmiden(tal Water Supply (single}
pindustriallCammel'cial
pRcsidenfial Water Supply (shared)
©Monitoring
- -
Injcction Well:
❑Groundwater Remediation
OAquifer Recharge
❑Salinity Barrier
z3Aquifer Storage and Recovery
C13tA�wat� i}rainage
❑Aquifer Test
❑Subsidenoe Control
q&xperimelttal Technology
00cothcrmal (Closed LDOP)
Tm
4. Date Weil{s) Completed: "l "ate —Well ID#
5a. well i,ocation,
PaaititylowocrN roe FaeiiitylD#(ifapplicable)
Physical A14tke0, City. and Zip��
••�— '-�" "" parcel Identitieagoallo. (pihi)
County
d
ib. Lntitude and Loogltude in egtceslmintltes►seconds or decimal degrees= .
(if well field, one ladlong is sufEdcot)
w
6.1s (are) the well(s) 4,.M,nent or LTl'empara�ryy�
7. is Pots a repair to an existing well: O yel or .l dl
fh+ty fs a repefr, fill nut fmoan well crrnsrrucrron rnfnrnrarrmr and explain the nature atoft
rf
mpafr under &71 remarksffemlan or ou dw back of thiafom+-
8. Number of wells constructed: _ u Garr
For mulf#p1e taJecOm' nr non-waferxuppfy wells ONLY wtdt the SaW cm�arue&an, you
submitoneform, t OJ4
9. Total well depth below land sorfacc:
Por nlulnple Wfls lost ad deprhs IN&Ont (example- 3@200'r+n42@108')
()
14. Static water level below top of costing:
IfilQrer lever is above ceasing use +
11. Borehole diameter:
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fa�a`t31 5,)n Ptri:f
22. Certificatiau:
S, I i
e LL Dar
8i anun orcm1itied well contractor
ay atgtring Nrfs jnrnt, I hereby rerfjfy that the vretl(a} was (were) Cansaucred fn accordance
n7tlt 13A NCAC 02C .OIOU or 15A NCAC 020 .0200 Ws11 Cmslftrctton Standards and the, a
copy of rbfs recntrrhaa been prW1d0d Io the wort owner.
23. Site diagram or additional well details:
you may use the back of this page to provide additional wet] site dewis or well
construction details. You may also attach additional pages if necessary'
suomm ALINSTUCfIONS
241e. Ea_ALy1&:
Submit this form within 30 days of completion of well
construct -son to the following:
l ivislou of Wattlr Resources, Informatlon Processing Unit,
1617 Mail Service Center, Raleigh, ltiC 2709-1617
in
�� ONLY: In addition to sending the foot to the
addre wellm
24a above, also submit a copy of this fb within 313 days of comp
construction to the fallowing:
12. Well construction method:
(i.e. auger, wary, cable, direct per, eto•) Division of Water Roaoarces,ltuderground Injection Controlrograsn,
1636 Mail Service Center, Raleigh, NC 27699-1636
FO:WATER SUPPLY WELTS ONLY:24e, For Water sureyQ13a(gpm) Meth"Af test: Also submit nnc copy aF this form within 36 days ofcompletion of
wellconstructionathecounty health department of the county where
13hfeetloa type: Amount: — constructed.
Revised August 2013
North. DepertmentofEnvimmnent and Naturatitesanrces-O'visian ofwaterResawnos
h
Form OW-1