GW1-2023-02924_Well Construction - GW1_20230420

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• -y ` �`€SJ I.;_RECORD( Y 1 . ForTntemal Use On►y-
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rI fl•Well Cu tract orlhforrnation:
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s 1d.WATER Pd1IVES
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16 R1NNr3R CASIPTG®R TODING )
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-• , 2.•WeR�asbruction'Permit#: T(l
' ± List al! • FROM TD DIAMLRTR.R THICKNESS MAMMAL,
+?PPbie emli mnmrraton permits 17.e.(EC Coarrtp SfarP.'Yarrartct etc) rl tt too`
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t 'WaterSupplyWell: • 17.SCt3EE
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unicipallPlEbHc ft. in.
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` ;. Geothermril(Heating/Cooling Supply) E dential water supply(single) ft. R. in.
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ldOn-Wale{' FROAi 17.O DiATF]iIAL EU9PiACER�N7'aSETFiOD&AMOUKr' 1
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aMonitoring C �S • • 'i
Recovery 1 i
_ j Injection Well:
[: { OGmundwaterRemediation
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.ii -Geothermal(Closed Loop) DTIUC tL 20.DRILLINGLOO(atte eddiioual dyads it necessary)
; Genthemtal(ReEtiag/Cooling"Reblm) iOther(explaiaunder#21Remark,) FROM T(' Di R>Ptaont`°tor,Uortam,�onrmacgPSEnlia:[zaem)
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., 4.Date Wef(s)Completed: '/2 21well.TN, iS 305't. XYi-i..-_
Sa Yell Location: rt' rs:
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- u Ct'S Y /, / - .t _r'cidd _ n2I^• HI to LJYhyAddcess City,
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11.,; ,• ,._1 ( -s, - - 'ZI.Ruvvuu ) 11 E941N J•r:. ,I [1.. / 't- .j .J1...
.it I'. County PaicelIdenii cationNo.(PIN) , . E _;";-.,-,
seb.I DtituBe and longitude in degreeslmiuertes%seconds or.decunal degrees
EC (irwei.d(gd.one lat/ang is su&cient) 22.Cerdficntion•
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•/-: f'Is(sere)trewepc ermaneut or'°Temporary
Sigaaturco atifinlWenConlmclor ]) '
eysign{ng tb!sjorm;Ihereliy ccr0fp that the nol!(s)unr{were)corutrDded in a000rdance.
7 As this arepair to an e>tis6ng well I�Yes or o t hsi8SA NCACOIe,116 or ISA NCAC 02CO200>flell.Coar'
i ifthisisarrpofr,sil. met/aoxs7;sellcorsdiaraninjormaog ander 4fridienaw:,ofthe fwp PINEirreomdhatbeeaprovidedtothewellowns, df°nStandardvandUwta
I,. repo""aster#Z!regwis section ar on the backajcias• hn ,
• ed. 23 Stte d}agram or adiiitioDnl well details:
$c.•,, uctroA,onl GW@ 1'is ae, L o7F,., , •GeotherniaWY�[)MB?ens e t we
a Yon m iimi del hack of tliis also attach additional adtli page well site deta.i]s or well
. wnstluchon detnOs You mayalso tutscll additional
(, drilled ` SQBNiT1TAL INSTRII2•rrnwEe Pages ifnecessaly.
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9 Total well 1 11 helaw land surface. •3O 7 � ) 2qa For A➢1 Welts•
Forrmirilpleivrl/slis.,andipri+srfdlffe,:inioamPk-3Q200 ca J00). � -- Mowing:mit this fortm vvtthia 30 days of completion of wen
IO;�te�ewsEeeleveLbeloca.iDp,of�sing (ft) IEivlsEano1WaterResotlrc
I= 1fr levetrsaGa*carm&:rye +"' Bono[ p ernes urcese`�ormatronYmExssiegUnft,
t.: e Rnle[g6,PIC 2T699:161T
21.1Beteholediaate+er ( )
1. iecblDn{;/ells
�_, - ;. aIsosu�bmlt.o y e g the farm to the ad
Fo
aSovF addition to s
a" 12.Wd'eomstT!Ieton�eSsoda t . y coDstmctiontnthefollowing affh>s;g dressis24a -
C�ono;iumcy,y39ie,d�ctPm%??c} QDn t)days of completion of"well
' Division of 636 r 'IInderge u»gnJeetion Co
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�.� �etleod o5test• �� ' 29r.For QVater Su P�,iVC`29699-fl63fi
1: lea h--., ) ddirss Ila: In addition to sed
G` �(� r/ �!�' the a (es)'above, alm submitn� e m
136.13i�i®te o�.¢pp _ l •
maernt: !(/1f/C::r completion of well c one coPY of tt»s fo g the form o
where
constiucted. construction to the coim within 30 ,of tY health department of the
jNorth Carnliaa�gaumsutofEaviraamea�(loam- c tY ,
Fain3GW:l . - , - -DEvisionafwahritesoulr�s
= 2-22-2016