GW1--03764_Well Construction - GW1_20230602

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• 2.Well Construction Permits: /3 / 7 MOM TO owning TA[C)C1ES4 MATERIAL
L st'tl applimyre weUemmrver on gem t(l e.UIC.County.Stare,Variance.etc.)" it tr. ID.
3.Well Use(checkwell use): rt. fr. In.
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0Geothermal(lleating1Cooling Supply) Residential Water Supply(single) R. te in. -.
)lnduetrialiCommereial DResideaual Water Supply(shercd) ,,,,.�,w;,�;,. _..._. ` s -•:
,brigation PROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
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Experimental Technology 13Subsidence Control - rG R.
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nGeothermal(Reating/CaolingRetum) Maher(viola 7Ob[ TO DFSCRIPr[OY(color ndnns,solVtvckl�C)fct+Nece,cu)
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Count) Parcel ldemificatiae No.(PIN)• Sb.Latitude and longitude in degreeshnInuteslseconds or decimal degrees:
. �W�en��`bi.an���� �)x �/ (' l `) � w 22.Certification: • p�,�j g g-
iqrk,t_ LIAW aldievi-573/71-2))
6.Is(are)the well(s) Permanent or )Temporary Signat ue o mined Well Convector Dee
By 41ning ids form.I hereby car*than the ra(s)war(were)contented at accordance
• e 7.Is this a repair to no existing well: ❑Yea or o with HA MAC 01C.0100 or iU:CAC 02C.0200 Well Commotion Standard,and that a
((this it arepaf,fMmabroinrwdi emurruelioahlarmaria,anderplaar thenahm of the copy of ens record has been provide(to thenell ornrer
repair andera21 remark section or on the bock 4'ddsjonn. •
23.Site diagram or additional well details:
• 8.For GeoprobelDPT or Closed.Loop Geothermal Wells having the same You may use rho back of this page to provide additional well site details or well
Construction,only 1 GW l is needed. indicate TOTAL,NUMBER of wells construction details.You may also attach additional pages if necessary.
Milled:
�� ,$UiIMITTAL iNSTRtICTTQ YA -
9.Total well depth below land surfaces (it.) 24a. Per All Wells: Submit this form within 30 days of completion of well
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For mntapir wear(rrr ail deprh.Jtipetent(example.3(a)200•and 2@l00') construction to thefoilowing:
10.Static water level below top of casing: if (eta Division of Water Resources.information ProcessingUnit,"water latent above crying rue+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 14.l (In.)
t 246.For inlection Wells: In addition to sending the threw the address in 24a
12.Well construction method: P(,`to,r about,also submit one copy of this them within 30 days of completion of well
(i.e auger.rotary.cable,duect push.eta) construction to de following:
FOR WATER SUPPLY WELLS ONLY: Division at Water Resources,Underground injection Control Program,
1636 Mail Service Centel...Raleigh,NC 27699-1636
(Cpfn) r t� �P�
13a.Yield Method of test: �r�11•' �(r- 24e.For Water Sunnis*&Infection Wells; In addition tii sending the[ecru to
j /� tine address(es)above, also submit one copy of this fame within 30 days of
13b.Disinfection 1 l r Amount: • completion of well construction to the county health depanment of the county
where constructed.
FarmGW-I Nona Caron=I/ma mmatafl:avimnaieoralQualiry-DivisionofWate:Resource Revised2-22-2016'
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