GW1-2023-02113_Well Construction - GW1_20230303

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1.Well Contractor Information: I 1
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tt 1Ve11 Contractorivame FROM€ I TQ AESCRmTJON
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` NC Well Contractor Cettifccation Number Z
IS.OUTER GASING for ulti-casea wells OR-TINEIt tfa ucable
l Nar TROhi ITO DIAMETER T99HIC�ICTIESs MATERIAL
CampanyName` ((� +i ft �&J It G in. 5DR-2l q2,q.
2.Well COJ1StrUCti0FI Pernflt#- 3G 7I s1 16.zmlYG�9 SINE ORTIISvING{entharmal clased-too ) rf C•
kROHL {TfT DIAbI>fER T9Jm as MAMIAL
List all applicable sell construction permits(i e:&yc Cotrntl;Stag F�mirntse etc.1 ft.
3.Well Use(CbeglrweR-use)s
ft
ft. in.
Wafer Supply WeII: i7.SCP.EEN I `
: Agricultural FROM TO I ' DLIMETER SLOT SJZC THICKNESS btATER
JcrpaUPublic ft
Geothermal �
` rmal(HcatinglCooling Supply) Residentral'dater Supply(single)
ft: in.
! Industrial/Commercial DResidential Water Supply(shared)
Irrigation 18.GROUT
FROM TO 1NATERfAi EMPLACEN!)t\'T1a1• OA&AM Mon-Water Supply Well: 0 to ft
f Monitoring Recovery Q Pow
j I}} to ection Weil: ft I it.
IPU tAquifer-Reebarge E3GmundwaterRemediation ft ft
{ Aaaifer Storage and Recovery �(SaiinityBarrier S ND/GRAYELPr4CKCtfa lieable
FRObT TO' MATERIAL EM LACEiSiWT iklETEHot
Aquifer Test OStounwater-Drainage ft ( ff.
�! Experimental Technology DSiihMdenceCoatcol f£ I ft
Geothermal(Closed Loop) -riacer 20.DitIE LINGI;OG(attach addifionalsheets ifnecessa •
Geothermal(l3ealing(CoolingRelnm) flther(explamunderr21Remaft) TO nFSCRtr'itua(cotoslIardness,sorumeStr eriiasv�
��� ZZ 0 � 93 ir. Dir
4.Date Wells)Completed: Well ID## tt, it
'' Tq
j' Sa-Well.Lacatian: ft I ft
1 f ft. I ft,
ISeSS
} Facility/OwncrNamc Facitity W#(ifapplicable) ft. I it.
Il �1fS� r��1�"can �QAJ'K' P Cf!en fya/ _LT �zww fr1
i Physical Addtcss,City,and Zip ti; I f. -4-
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I Ashe- W271—M '-C�— �I.l�ll � i _
County - Parcel Identmcatioallo.(PIN)
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5b.Latitude and longitude in degreeshitinutes(seconds or decimal degrees:
j (tEIvctr Hojd,w&laWoug iasuf$cient) _
22.CertilICati
6.Is(are)the wells) rmanent or E3Temporary Signatum OfCem&eiI WeII na Date,
f By sigaing this foim,I hereby certify that rite uTil(s)tvas(spare)constructed in acc
f 7.Is this a repair to an existing welt: D3�es or gN, TV191 IS_4 NCirC 0?G_01t?d or ISif NCf1C 02C.02U0 lire!!Coastnrctian Standards cr,
f ref air7i a repair,rent pot(atawn well construsliorz irJbrmatiotrand explain the nature of 1/ra -pyafthisTecorr)has bamprovided to theivelrmmer.
repair under r2i remarks section or on the backofthisform
23.Site diagrallt or additional well details:
9.For Geoprobe/DPT or Closed-Loop Geothermal Wells baving the same You may use thie back-Of this page to provide additional well site details
' ! construction,only l GW-1 is needed. Indicate TOTALNUIIQBER ofwells construction de".You may also attach additional pages ifnecessary:
drilled:
SUBMITTAL.INSTRUCTIONS
I 9-Total well depth below land surface:_240 {ft.)
! I Forraaftible lvatfs fttall depths ifdifferetn lhrample-3 a(�00'aad 2©.Z00) 24a-LOT All—Wells. Submit this form within 30 days of completion
t - 1 constmetion to the following:
10.Sta_tiawater level below top of casing.
Ijlsatet level is above casing,use r^ (ft) Sion
n Of Water Resources,JnfOrnmtion Processing Unit,
I'I t I 617 Mail Service Center,Raleigh,NC 27699-I617
f' 11.Borehole diamet$r:G/ 24b.Pot Injec In addition Wells: additiontoon sending fire form-to the address
i {�
.12.Well construction method:A(r P1D tt�1 above,also subili t-one copy of this form within 30 days of completion
i {ie_auger;rotary,cable,direct paste,etc} construction to the fpliowing
FOR WATER SUPPLY WELT 01-iLY. Division of,Wl aterResources,Underground-Injection Control Progr
1636Mai1 Service Center,Raleigh,NC 27699-1636
I3a.Yield(gpm)S® Method of test: (� ff
Q +I LI�� 24c.For Water tSunniv&Injection Wells: In addition to sending the:
ty, :, `�H Amount: L1t 67- the addresses) above, also submit one copy Of this form Within 30 c
i 13b.Disinfeetion e. l completion of WC1 construction to the coup health
1 where conshuc
1y depattzrtent o£the
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