GW1-2022-10758_Well Construction - GW1_20221209

WELL CONSTRUCTION RECORD
I.Wen Contractor Information: For Tlltemal Use Only, �-•.n-ter,
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dleonrduetronpermltr(Et Inc !o State,t'mlaaea etch iROH TO of e � `•iMC ,:i•ry: :x=;
3.Well Use(check wen use): ft % tn. 1►tA7 jN;
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ion 0Residential Water Supply(Shared) & in.
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oring ftTtaltubuce�yExrMeraond<,iiKp r
Wen: � 03' R .rRechargerStorageaadRecove 0�� Re°lediationr Test ry 13SaliuityBatrier Fop' lGRAVEGPAQC ti' Earbte>„l r;,;*,�;:;w t.•...r
OStonnwaterDrainage TO e>i►mwr. ;<;^�`s�tYMr•a'Y,�;r a: •:
Experimental Technology R it ter"�� Matson
Geothermal(Closed Loop). Subsidence Control
Geothertaai(HeatingJCooling Reps Other( fain under S21 Remarks) 2 Tom ei�Ch �d DES 4.Date W =atKbrs •u t;;, ,r:-':fit:
ON Corot hons.aoatmer:" e "
Well(s)Completed: �- `-biz- W� C� j tl� ` •: ew
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m# / n -5
Well
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Fac�ty/GWnerName _ R' ;• .
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Physical Address Cny andZtp //c r I it Cr ft ftd. r
4­1 4J Z�6 73 ft. ft
Cmmty e.21i a7l thvS3J^kRlj l NA
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steel Identification No(P>M "t�%, :�:
511.Latitude and longitude in degreeslublates/seconds or decimal de
(it wets field,one ht/long b saffieient) degrees:
a &
Nth r W 22.Certification:
6Is(are)the weQ(s)09ermanent or Temporary
s •�uuea wort Cannacror
7.Is this a repair to as ezisting wep; Date
lithlr Is a repair till outl6emvrt well I..IYes or tv�lth thtriemr I e�eel that the well( —(were)con:
oucdon igjomradon and ezpfabr the nmre NC+fCO2CAl00or ISANG(C 02C.02W tYdlConro%wj bs aeeordanoe
repatrrmderfl2lremarkraecttonorOndrebackoftldsfornr. gjtha _PyOfth/s andtlrata
moMhaebeenprwldedtolhervellmvner s
8.For GeoprobeMPT or Closeti-Loop Geothermal Wells having' same 23.Site diagram or additional well details:
�nstructioa,only i GW l is seeded Indicate TOTAL NUMBER of wells construction dYou MaY use cal back of this page to provide additional well site details or weU
eteils You may also afth additional pages if
9.Total well depth below land surface:` �M1Tl'AI.INCTnrrr►rrONy necessaq'
FormOlUpleweJ/r/trtaildep/hrtfd8errm(ere,p�va�200 and2Q/pp�
24s, or eQs: Sabin$this
20.Static water level below top of casing; coffin to the following: form within 30 days of completion of well
lfwarerlavdlraboveear/n&are+" (R) .
Division of Water Resources,infor,'mation Processtag Unit,
11.BorehoIe diameter: d n 1617 M R Service Center,gal
.NC27091617
12.Well construction method: 24b.For Infection Wdh: addition token
(i e.anger.mmm cable,dk.g r`I above,also submit one copy of this form c f 0 da the ys to Thef c mp etio�f well
pnsb.etc.) construction to the following;
FOR WATER SUPPLY WEB ONLY: Division of Water Resources,Uad
13a.Yield 1636 M U Service eYg�ound Injecti°a Control Program,
(gPm) �� ��'+��.NC 27699=1636
Method �; �--
24c. r Water Snooty&Infeceto,.w i.13b.Disinfection type: Q the dif
addresses)above, also submit one'co of dthis on to sendi0g the ions to
Amount: Z r completion of'weQ coast, ions within 30 days of
where constructed0II to
the county health dePaent of the county
Form GW-1
North Camliaa Department of Envimnmeatal Q-My-Division of Water gesomees
Eevaed2-2Z.2016