GW1-2023-02397_Well Construction - GW1_20230404

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LL 4CON SMUCTION]Eta+COIgD MM-11 For Fraternal Use Only:
1.W-ell—Contraetac Information:
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lVellContractorhamc FROMTQ DESQtIPE'fOiY
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NCWeACnntmcwrCeitificationNamber qg:p g � mofd,tatsedleeVs t)$L1[NF,tttlr >
S moll To l3FAR11;TEtt THIt�NNEES4 3tttTIIRIAL
CompanyNanteen M-RO B CAS: G01LT!3$ITlGf eaffiermdelosed la0 )
Z. t@!1 C�n�trtrc off Pe£Imi[r€: 3 -Q 6> FROM I TO I nral«t I
Tl�rcx£a�ss ��sarar.
MIullappIkablehellcontlaicdanpermirs(i.e.111C.Caalup,.7me,Variance,etc.) p n• Q' (�. ZS'n- 15DRZ 1 VC
3.Well Use(ellecls well rase): ft- fi in.
1Vater Supply Well: iT.5CSEEl�ff
FBoSt TO nLVlWEp SLOTS= T1MCt.1ypSS ASATRRTAT
AgriculturalIvIatzi ' b1Ic rt► .
Gcathcrind(HeatingiCooiing Supply) UKesidealial Water Supply(single) . ft in-
Industrial/Commercial E2Residcntial Water Supply(shmd)
IETt atiQll FRMI TQ titATERIttL E�ipL,>CE�i&\ThiEtADB&�SI�I06TT
Nan-Water supply Well: ft. CX> ft. ��,(�
MonitatYng DRecovery R. ft.
lWeation Well:
` Aquifer Recharge DGroundwaterRomedmhon ff R.
le quirerStomge and Recovery DSaliaity Battier FROMTVE>iPAC�ataa�ttt
Eh1PLdC�t6:4T B1h'rltOII
AquiferTcst 0SttmnwalorDtainage rt.
Experimental Technology DSubsidence Control
Qcuthermal(Closed Loop) 0-Tracc[ ?R.3)I LII+1GF.f3Gfaltaefiadr3iBm+nishoe�if
GcOthcrlaal(Hearin /Conlin Rcltttu) Either(explain underM Remarks) aRQat To BEscttleTtoutmTar-hasdnets soilfmrY sou ael
p rr. q 6 tt.
4.Date WeUfs)Completed.Z'sZ -23 WeIIID# (o % 30S' a•
So.Well Location; $• tT• _,
O-Anoi.,,—1 en l7. Q92-C4
rwilltylowuerName Fact7'ity1Ds(If apPIIeabte) 4 -
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Phyts-icalAddress,City,andZip o? -]� Et ft. J y
d rav\su kyah�0- �Sy�-80- 1-78y-aoa �-�
Courtly Parcel Identmeation No.(PIRJ
Sb.Latltude and 1014tudein degreeslininutes(seconds or decinud degrees:
(if well field,one ladling is sutFicmnt)
27,CerBficatioa:
,6b 131 -Wecb>.271'l �a°51 ' fig.q��13,�,'! �►
�Xmtarcificdwcucbatoaclor
�Us(are)theweil(s)• ermanent or �Temparaty Dale
&v slanuig this form,I h-ehy eentfg that the u-Puls)tram(here)carlrrrurled in accordance
7.Is this a repair to an existing wen: Dyes or O itith ISA NCAC 02C.0100 or ISA.NCAC 02C.02a0 lVelf Com1mctiwr Standards and that a
IJrttsirarrpatr.fittest[&uiou7suettcattWruuioninformusiorraaderptaiadienatarrofthe -IV gfdiirmcord fins Beenpravwedtatheivettoxner-
repair underr2l remarkrsectionor on.the had-of&Worm. ,gltc pP Or8dditioanfiNelldettlils:
9-For Conprobell)PT or Claced4.00p Geotliermal WelIGIM tog she awns You may use the back of obis pages to pw ido additional wen sire dcsatLs yr zvwi
cou'jumalon,only I QW-1 is Uguilud.Indio=TOTt1E,NUMIMR orwcUs consriucdon detalls_You may also,aunchadditionalpngos ifacecsawy,
drilled: SiMRj 3MA.i t�tertar CTIO
9.Total well depth below land surface: 24a.For l Wells, Submit this farm within 30 days of completion of Weil
Formaldpte i¢ells itstatt deprbs iTdFfffrtW(emmpir3@200'and2@I0,91 constructionto tiro following:
Ia.Static water react below fog of casing: (fL) Diviston of WaterItemurces,Information praeesd y L•tdt,
If+rater level is above casing,use"= 1617 Mail Service(;enter,Raleigh,NC 27G99.161?
iL$OrehOle diameter: a (in.) 24h.Far bleetiolt Wells: Ia addition to sending the form to the address in 24a
12.Well construction method: above.also submit Ame COPY Of this form within 30 days of completion of well
r c.augcr,rotMy.cabic,(lftcrpusk=) COR5I1110U01i tot11C 10110wittR:
Illvisinnef Wader l ttrces,Undt>tgrotmd Itoljeclion Control Program,
roR W&TEx SUPPLY WELLS©t+ll.Y: 16M bail SRViM Center,Raleigh,NC Z76991636
139,Yield(rpm) Method a€test:TA I C� 24r-For-Water S WIX&inia rtinh M&&: In addition to sending the form to
the addtess(es) above,21SO submit one Copy Of this from Wilhin 30 days of
13b.Disnlfeetion type- ( Amounih 3 �—d� completion of well construction to the county health department of the county
whPm coustnlcted.