GW1--03155_Well Construction - GW1_20230505

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WELL CONSTRUCTION RECORD 1GW- .l • 'For rnternal Use Only:
1.`Well Contractor Information:
V arni$rtIN Gt bsnr3 14.WATER ZONES
Well ContractorName
ROM TO t DESCRIPTION
`[693 - 14 1 ft.6 53o G '�}clloea
NC Well Contractor CertificationNambes \ q3 OiPrERCASDIOlformoltl�casedwells)GRUNERtitan ' el
v 1-At1LJ } I IAt^ MOM ft. ` TO ft DEt6lET2IIin_ THICSISESS !damn
Company Name 16.INNERCBSINGORTQBING(geothermal ctosed loop) .
2.Well C nnIruethnli Permit FROM TO 1 D1AMETRR THIC -MATERIAL
List all applicable nil construction permirs(i.e.UIC.Courtly.gate.Variance.ow.) 0 R' Sr R' G. 2C in' Sr -Z 1 P✓G
3.Well Use Mega welt use): R. R. in.
Water Supply Well: 17.3CSEE1Y
gticultttral FROM TO DIAMETER SLOTSIZli THICIOIESS Mils mtL
MunicipalIPublic ft. ft. in,
it Geothermal CHcating1Cooling Supply) DResidential Water Supply(single) n.- 1 ft_ in_ _
*Industria/Commercial QlResidential Water Supply(shared) t--�- { -.
1B.4;RtDUT -
'�'Fcigarlon. FROM TO MATERIAL EMrLACEIci rijEFHOD&AMOUNT
Noa•Water Supply Well: 0 ft- aU ft- ge]_M:k f�y�
X Monitoring EiRecovcry ft. ft. C_1l
1 n jection Welt: � �`P
ft. ft.
IAquiferRecharge EiGroundwaterRotncdiation IA SANOIt .iVELPAC tirsaplmabte)
i-quires Storage and Recovery MSallnity Barrier BROX TO r DIATERTE EtrPLACL1fENT METHOD
it Aquifer Test OStotmwaterDrainago R• ft.
i Experimental Technology °Subsidence Control ft. ft.
WI Geothermal(Closed Loop) DTraccr ' 20.DRILLINOLO4fatitich additions-Ishoetsifatecsssatha —
•Geothermal(llcatingICoolingReturn) Other(explain under#2I Remarks) FRost TO Dt?sesterlolurs�mr:batan ,mtlfreclrt .�ta,;u set
. O ft. 3? "` C.lay \
4.Date Well(s)Completed: y—?0"23 Well 10# .3 q n` leOr f Cl rexht 7..e
5e.Well Location;
+�c Me.��sse �.l�f Q� ft. Fc,
Facility/Owner Name J Facility MtCidapplicabte) fr.
132Q Dt.La s . MI Neetlntresk��to, Ne ft. MAYK 2023
Physical Address,City,andVip it_ ft. a
t�ui.7 ...;i i''1. . !.] t R:1
Rehet rson as 1 a 016(12 Iv_ g.REMA t {.opt/3Lh -
County Parcel Identilicetion No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decline!degrees:
of well nerd,one imilong is sufficient) 2z Certification:
,35v 3Q ' 35.3-t tt N no 41 I act.551 i' w y- 26— 23
6.Is(are)the well(s) ermanent or Temporary tgmnite oft:crtified Well Contractor Dale
By signing this form,I hereby certify that the netts)was(were)constructed in accordance
7.Is this a repair to as existing well: Fes or IYD with ISA NCAC 02C.010O or ISA.N(�`I 02C.0200{pell Construction Standards and that a
Ifdds is a repai:flit our knamt wait constrnetfan infarmatiaa and explain the nature of the ropy of this record hat been provided la the wen owner_
repair under 021 remarks-section aroathe lrackof thisfonn. ,Site diagram or additional well details:
li_Piar Ceaproba/DI)T or Closed-Loop Ceatherrnaf Was having the came Yoe may use the back of this page so pmuide additional well site details or weer
construction,only 1 OW-I is uuedcd.hullo i TOTAL Numb R orweus commotion damns.You zany also attach additional pagec t neaecanry.
drilled:
$URhIDTTA.T..iniSl itUCTIOPSS_
9.Total well depth below land surface: (P O ' (f) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple welts list all depths ifdi]faent(e ample-3 a a0'and 2@I00) construction to the following:
10.Static water level below top of easing: Td (ft,) Division of Water Resources,Information Processing Unit,
If tenter level is above curing,use' 1617 Mall Service Center,Raleigh,NC 276991617
I1.Borehole diameter: (O. 2 r 1(in.) 2db,For Iniection Welts: In addition to sending the form to the address in 24a
�'Or is.welt constriction method: q„%cvn above,also submit one copy of this form within 30 days of completion of well
e.auger, uny,�lc.drrrcrpush,sic) construction tote following•
Ci
€
Division of War Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 276991636
13a.Yield(gpm) I Method of test; CCU. Cm„n 6142,...For Water Supply 8r Infection Welk: to addition to scatting the form to
the addresses) above,also submit one copy of this forth within 3D days of
13b.Disin€ection type:04 rlr Amem tt (.R ket..6.3 completion of well construction to the county health department of the county
where constructed.