GW1--04667_Well Construction - GW1_20230721

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DiStttanvra Drainage ill TO 14 MATERIAL sens�eCEMET METROS
MI -,,.,'„1 total Technology �_— {
itGoOthermal(Closed Loop) D $"
��� 20.DRILLING LOG(attach adOtIonal dolts if strassa . I1
al heamal t:: :..,.,_i : .,,Ramo a OthEe ..1aia uuder#2l Remarks) wont To D en m fmt� 1
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4•Date WeIt(s) (�
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FocolayithmerNams
I I I I 4 .1. 9091
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PhysicolAddress,City,warp
T 2LRE&lAIIKS •
County Parcel Idemitiptisallo.(PIN)
Sb.Latitude and Ifingitude in de rcm/ninnies/seconds or decimal degrees:
(ifwell DeIti.azaC haficau is )
22.Certification:
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6.7s(efe)the wedt(s eamaaeat or Ej I'e m porasy EgmmteofCatified WoU Cnatauior W
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9.I6 title arepair to anBY was this 02C 1Itertby i'that do�(r)mar(tor)coahnieted ha armrdaaas
existing well: Yes ear No with ISM!tYCAC DZC 91�orlSutlYGlC OW MOO ggp
ljrhEv6argsalr,Jlllorrtf�oevnwrpeoustruuirawa ing° artdesjo&t4e=awe a, eopyaetSirnxmdlasbamFmrfdelfe& maw. dad theta
mix&ander ff21 emeil,s se donareathebeekajthis forte.
23.site
aware
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d.For GeoprobeJDPT or aosed.Loop Geothermal/Welfa having the same You Y usedt .Ye the heck of this psgt tt Pride well eke r.Ls or well
consfrucl' only 1GW-Iisnet Indicate TOTAL NUMBER.ofwells
ttmayalsoutt a �
drilled: /
9 Total well below land surfaces ma.Bar.All Weibn Submit this Runt n I
Farma(8ple deptArijdffenai(emarpge-3�t9D'tmd2@IOft') ) ar to the following: vritlim 30`days of completiaa of well
I0.Statle water level helm top of easing: ct (ft.) D1vfslota of Water Resources,Information o
rimier level&abaveeusng we+^ r 1637 Mail Service Center, l�rorxasfao III' !
11.Borehole diameter et
(ire,) Infection W , glt,NC 27699-161? j
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24h.1retr ells: 1n eel tlen to sending the form to the address in v
12.Well construction method: `®k�w construction above,also submit
a ollowln of this form within 30 of completion of well
(i.e.auger,rotary.cablg daatprsh,ow.) -•
FOR WATER SUPPLY WELLS OM: Division of Water Resumes,Underground Injection Control
1636 Mail Service Canter,Rrtlelgh,NC 27639-1it36 Program.
t e(
0f i�f�l', 24r.For Water Sunnis,&Iruit8srn Welk: In addition the f
13a.Yield...— Method of test: / the address(es)above, also submit one copy of this to
13b.MaiinfeetIon type: pasouat: �� completion of well txmstanctioa to the county health d eat 30 tt>4Ys of
�� where,constructed. -` of the eman2y i