WI0100466_Geothermal Well Construction Record (GW1)_20170123

i� CV ST UC " i E C!__ 11 1 L., I l� f Far [n I Uaa.CNLY: .
7'ivs fmtn ten Ha used for single or muldplew
elie LJ t V 1.. k.1
i]ivisinri of Watrtr Resources
I. Well Contractor luformation;
Well Conuu r Name
;k r rs T-u—LerrfkER
2603-ANC
wallContramorCerhficeaonNumbu
AWf} StsrviC@8 inC.
Water Duality Hey}onal operati
Poi Dior ed:Welts •t)kC ' IER:.; - ' ....
l=614e Re ional office
2. Well Canstructiaa Permit #: W10100466
ROM '
R,
n
rxr MAURIAL
Llslalf applicable well construcA0 pem#1s (i.ff. COW*, Sian, Variants, ejej
1360
IL
3. Well Use (cheek well use);
J.
ft
in.
Water Supply Well:
17.:
rROM TO
a�r¢x
i :.:
S s S M Tl
t7Agricultural
❑MunioipallPublic
ft.
sa
OGeathermai (FkatinglCoolingSupply)
OResidential Water Supply (single)
&
ft
'a•
DindustrlallConmercial
❑Resfdential Water Supply (Shared)
1&''6RdII-
❑rrri tion
PROM•
L''• EMPLA M
Non -Water Supply Weil-
- ft
j -__P_UWPed
❑Monitoring'
❑Recovery
Injection Will-
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❑Aquifer Recharge
❑Groundwater Remediation
19. Sd1VDNGIszq..
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❑Aquifer Storage and Recovery
❑Salinity Harrier
MA
..
Barn A ant�nri n+Lrxo
❑Aquifer Test
139tormwater Drainage
R.
fw
❑ erimental Technology
�P !IY
❑SuhsidenceControl
fts
ft.
atherfrial (Closed Loop)
❑Traoar
2ti:11RtL '
gtt6ikAkse�r.lfa
❑Geothermal Heatin Conlin Return
❑Other laintlnder921 Rematies
M TO
tL
ft•
color Lndn aofllraek q did
4. Date Wellted s) Comple: 1 /11,117 Well ID#
fr.
ft.
5A. Well Location:
fp
(A
Mr. & Mrs. Cliff: Williams
Faailitylavrner Name
Facility MN (if applicable}
ft
{L
Physical Address, sty, and Zap
Transylvania
ILRE
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01� 1r;mllori PrQc�...
County
Aarcal Identification No. (MN)
Sb. Latitude and Longitude in degreestminutesheconds or decimal degrees:
Ofwoilfw1d,onelatllonsissufficient) Elev, 3073'
35 7' 13't N 82 56' 42" W
6. Is (are) thewe[l(s)I dermauent or t7Temporory
7. Is tbis a repair to an existing well: ❑Yes or N14
l'Ohts 1s o rspolr, Jill 001 known well construction Warnuldon and €rplatn the nature of the
repair under #21 "marlls secttwn or on the back gihisform.
S. Number of wells constructed:
For mulltple lnimlion or Peon -water supply wells ONL Y wlrh the same;7w s_&at on, you can
submri vm)brm.
9. Total well depth below land surface: 350' 2 275E (ft.)
Far mutlple wells list ill dap182 fa fjerene (example- 30200-and1@100')
10. Static water level below top of easing. NIA (fw}
lfawterlevel lsabove Castlrg, use "+'.
il. Borehole diameter: 6.25 (in,)
12. Well construction method; rotary
(i.a auger, rotary, cable, difectpual� eta.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfectlon type. Amount:
7.2. CertidTicadon:
'' 1123117
S%nanu�e oft itified well caetrattaf Date
By signing thls form, I hereby ae"O, Near the well(s) war (were) comtrucled in accor'*mce
with 1S,f NCAC 02C'0100 or 15A NCAC 02C.o7o0 Welj CoastruNtda $lcrr rds end Thal a
copy of this reoild has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or Well
construction de;ails. You may also attach additional pages ifnecessary.
SUBMITFALINSTUCTIONS
24a. Fpr All Wells: Submit this form within 30 days of completion of well
construction to the following
Division of Water Quality, Information Processing Unit;
16I7 Mail Service Center, Raleigh, NC 27699.1617
24b6 For I deetion Welts: In addition to sending the fort to the address in 24a
above, also submit a copy of this foam within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24e. o W n Welk, lVadditiontosLridingthefbirrito
the addrm(es) above, also submit.one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructcd.
Form GW l North Carolina Dep-menu of&inrironmant and Nauusl Reaauaees -Division of Water Quality Revised Jan. 2013