GW1--04671_Well Construction - GW1_20230721

C
. WELL COW UCZI j I"r_Car n»( W]l For Internal Use Only 6��ie"col t.'
L Well Contractor Huformatioi;
-eery.Thompson 1A.WATLeRaONES.
WeIContmetorName FROM To•: .
DESCRIPTION
4418 A • .-1Yft 1_3'.N cc-pc.4o! !,...a f}i,yv.
NC Nell CantisemeCee teeationN®bee
IS:OIJTEf C ISRIG(tbrmalti:cosedsvells)OR IINEROf•- m6ta):-••.•.•.. 'Aqua ®!'10l, Ingo -FROIW TO Dram TRCrOESS% MATERIAL _
company •• d iti I z al c..zs h.. S 0 i 1` 160 L e.
2c •
IG WJP.3ER INSEIR-TRBINGWelbermaldaseii=l®ou)::2.Weil Construction Petit#: t FROM TO D�I� MA '
Ltst all appltcables ell ooasttaetlonpemuts ge.WC Counig State,Verrone.eta) ft _ (L in.
3.Well Use(check well use): a O. iti _
-
•
Water Supply Well: •
Agricultural -eipHlH►ublie FROM TO DLTOETES - sinTSlR GC S _AATGRi%L
•Geothermal(Heating/CoolingSupPly) dentialWaters 1 a
uPP Y(single) n ft. to. —
•industrial/Commercial • DResi eential Water Supply(shared)
- hrjgation 19.GtZOUT.. ...• :.. - • a •. :.
FROM To MATE81At interaimanN'ralartrOD6[ARIO er7
Non-Water Supply Well:. R 72.2b 1��
i+Monitoring Recovery f�''.k.; :t pv,,- , (-lye,
Injection.Well: fu fa tc.;rs t
Aquifer Recharge OGroundwaterRemediation - -
•
It golfer Storage and Recovery �Selu,ity Barrier -I •SAeDIGRAvEL PACt{•(tfapptimblo) • • .-
FROM TO MATERIAL lePLICEa INM.NE wab'Aquifer Test rjStormwaterDrainage ft re. •
:!Fspetimental Technology E3SubsideneeCoatral ft th
71 Geothermal(Closed Loop) DTracer •20.M ELLiNGLOG(setichadditionalsheetsifneressero)•-• ••-
ThOeottrennal(HeatinglCaoling Rearm) Other(explain ands:#22 Remarks) FROM To Dtstauenort(cares;to dee:e,•setv.e e,r mos sue.eel ' •
6 ft L fa
4.Date Weil(s)Completed:7`I�Well IDO CO a 7b i w 1 j 7
(�c-r 5 bey ga: f
3n Well Location: n,- /� f4 r. a
A*1—(i41 tti 4L,•ICSI rS 1-•1^�" �� t D �t�m� t$T�r�v�, $c; 1
`- 1� G rn�. I-
Faeility/OwnerNamo _ •Facility IDS(ifappth:able) �' fC Z.S f r _
. ....
/� ft CZ mraA; kz �` tr' �i� `
��-i q rcpA Ue (Niakh+t. Cov 4.r` ft.
Physteet Address.My.undEp ft.
•S46 ke:S 21.REMMt1CS J iJ�:,• .2023
..
County • Parcel Nentifieatien No.(PIN) e, w. ';,a Prr±r-y,,ke:fr'A'l.ini
5b.'Altitude and longitude in•degrees/minuteslseconds or decimal degrees: [ rOC
(ifweil field.ewefatltaagissufficient) 22 Certification:
U r7'O9,Zvi Ga'N P)6 1 I' 34. 6/f.5)-'' W .
6 fs(are)the welI(s), ermaneut or LjTemporary• Stone ..of•..., ,well Cc' znetor Date
7.Is this a repair to an eutabita welh By signing due fottn.1harrtiy cent&that die trdi(s)was(inn)contacted hi accordance
pa g Dyes or �y T�p irithISANCACO2C.0100orISANCACO2C.0200iWCaamuetlanStandarefsmaddmta
Pitts tsarcparkfrUautlatatrnardJlcanstrastronWormattonanderplatt&armoiretethe copyofdii mandhar been Padded fa travail otrnor.
raporrander821 reorarLtmaimtaraadtebaekoftltrsfatat.
23.Slte diagram or additional well datnils:
S.For GcoprobclDi�'or Ciosed•Leop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction.only b GW-1 is needed.Intlicate TOTAL NUMBER oftvelts• construction details. You may also attach additional pages ifnec ssar):.
•
drilled:
.15 SUBMITTAL EISTRUCTIONS
•
9 Total well depth below land surface: - (ft) 242.For All Wells: Submit this farm within 30 days of completion of well
Far multiple urns Install dapdtsV (example-3Qa 200'and2Qa J009
construction to the following:
IQ Static water level below top of easing. L.' (ft.) Division of Water Resources,information Processing Unit,
Ifawten oval tsahaveaastng asa•-" 16171bIait Service Center,Raleigh,NC276991617
•
1L Borehole diameter: 6, (in.) 24b,For Injection Wells: In addition to sending the form to the address in 24a
• 11 Well construction method: Ctit-0 t'.I (4:r above,also submit one copy of this farm within 30 days of completion of well
Ce a eagot rctt y.cable.daeatput%ear) i construction to the following:
FOR WATER SUPPLY WELLS ONLY Division of Water Resources,Underground Injection Control Program,
I636 Mail Service Center,Raleigh,NC27699-1636
- -13a.Yield(gpm) .c7 Method of task 64'- 4.Ir''e'`•L - 24e.For Water 5upniv&Injection Wel➢s: In addition to sending the form to
•��i.Ia� a• the address(es)above, also submit one copy of this form within 30 days of
13b.Disinfection type: Aaaount: I G VI- completion of well construction to the county health department of the county
where constructed.
Fenn GW 1 MonhCarolinaDeparauentofEnvironmeatta]Quality-Dvision°MaterResomee Revised2222016