GW1--04680_Well Construction - GW1_20230721

WELL C(ONSTRI TCT'I1 s WPM QG.W 41� For Internal Use Only. �e Ve rt
•
L Well Contractor Information:
•Oary.Thompson :7�zvAVc>P aOP1es .:,• .: :•.
1no �: • D�5t� pl{
Well CoonactorWame
-
441 A ' l o® f l ii s- 11 Cvnr.. c- "I b GI+:-w
f .1CW Contmewti`ee¢i6edennNianlxe 19 • fit' 1 a ft' CorY,"!�e^ �'o ��yr..
ES:011TER�CASMiii(ibtmtdtkosedavello)ORLINB1t'(IMi•tttalda:-••..•.-•:. ::..'
Aqua Dail, Inc. -• -FROM •� rantmirt �• n arAa.
Coa>paury Name• • a tt: i G 1 I Gp le rim I S 0 f' '-' Pbc.
2.Well Constraethic 3{aesruit f: G L.0 P II 03......0bs on G OR-Tllime G(deatbermal cieseil:I00):;::•: _•" .•
List allopplIcobte well anstracuanpumits(Le.=Cowut State.Variance toe) ft. gt. fn.
3 Well Ilse(cl►eeicwell nse): ft. ft • In.
•
Water Supply Well: •
culttaei most TO DIAB1EfE6 sLoTsI2E ^ TM•� I aresat rat
�ivl 'icipai/Poblic fa f ta.
Geothermal(Reatitg/Cooling Supply) , -Vandal Water Supply(single) fa• fa to.
Indistriai/Commercial Residential Water Supply(shareU)
Irrigation '80.mow.. .. :.. _ ..-•.• •.:.a •.• •: .W11111111
: ••::.•. ..
MOM To BETeRML IIi1PLAtB� • llll toD&AMOUNT Non-Wafer Supply Weli: 0 yy y ft.
(�il`e
Monitoring DRecovery ft, ft.• Q`y�l ��`� `��I
ffojection.Well:
Aquifer Recharge oGroundwaterRome;dietioa • - • -
Aquifer Storage and Recovery DSaliaityBarrier •
MOW TO�$•aaric(na )
AITOLSL Aquifer Test MCirr asEraon •
. �IStmtwatetF3rainage ft ft
`"Experimental Technology °Subsidence Control ft. fo
i Geothermal(Closed Loop) 0Tracer :2Q ORMONDLt)G(attachaddttioilalshoals ifoectsare)- •
Geothermal(HeattnglCooiing Return) JJOther(explain under#21 Remarks) FROM fa TO(6 ft. Drstm�rroar(eata,:r�nea.s�trmvsem�,a„m ate) •
4.Date Well(s)Completed:-1"11-la Well MP ft. ft.
do.Well Locaiten: •taVINtr� Gsvi—te.�e,c'� f a ft. f �� � �k1:��l1 5�C
� _s""� G i G:-bw�� •
kaNcu•s•4�5�a+rne�‘aS-c G/ ft' .7,-'Zr•ft' C>�Ar:11-e_
Facility/OwnerNemo •Facility 1D0(ifupplioable) ft IL i
•
—7Ina ri MO. a`��'4N4..rr:IL 11Nc_. ft. _
RVo -� 2118EIvlAR[(5 County Parcel Identification No.(PIN) II.V 4 ryfl 1 L V,J J
5b.Latitude and longitude in•degrees/miautes/seconds or decimal degrees:
fifteen field.one lateens is sufficient)
2.2.Certification: k11s3rtrewn r1 rYt-; ;ng if rn7
�(na:pt.'?`S7.S71f���N 47 9�'.5l ems' $dSS$°i �y DWCiiMOG
e
6 Is(are)the welll(s) ermanent or°Temporary• Signature of ofierl Well ContractorD tom`
7.is this a repair(0 an axis � 8ysign drts farm.Jhereby sere that die wars)was(owe)constructed to accordance
Paexisting well: ®Yes or EKt1°< with JSANCAC 02C•0100orISANCACO2C.02g0 WelI Cannelton Stondardsand that - •
Pis tsaoepat.fdl out PatmrnstelteonattuctIoninforraarPonandeaplatalhe nature ofdte •capyofditsrccotdha'been ptmfdeIndmu+eldouner.
tapatrunderP21remarksaecdoa area the adcofthtafomt
23.Site diagram or additional well details:
. &For Gcoprobc/DPT or Closed-Loop Geothermal Wells having the same ;You may use the back of this page to provide additional well site details or well
construction,only I.GW-1isneeded Indicate TOTAL ,construction details. You may also attach additional pages ifnecessaiy..
defied:
SUBMITTAL INSTRUCTIONS
9.Total well depth below brad nalif= "--).-5— Ve) 24a.For All Pops: Submit this form within 30 days of
Fornndttpleirellslistoll depths Ffdifferent(example-.10200'aaddat;l00q construction to thefallowittg: completion of well
10.Static water level below top of casing: LI d (ft.) Division of Water Resources,Information Processing Unit'
IfuntorterelIsabmecastng we"=" 1617 Mall Service Center,Raleigh,NC 276991617
•
11 Borehole diameter: C (ia) 24b.yor Iniection Wells: In addition to sending the form to the address in 24a
12.• Well caastauction method: c' c-� �v:r above,also submit one copy of this form within 30 days of completion of well
(Lc.auga:mtmy.eebra daectpush,eta) ' r:onsuvetiontothefollo�vioa
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276991636
•13a.Y ield(gpm) 3 6 Method of Yeah C.t ttN'a k.`\"NC.• 24e.For Water Suoniv&Iniection Wells: In addition to sending the form to
c G the address(es)above,also submit one copyof this form within 30 days of
13b.Disinfection type: • to/n Amount: \( `i- completion of Welt construction to the county health department of the courtly
where constructed.
FotmGW-1 NonhCerolivaDepartmentoffseiromrteantQuaii's,-DirisionorwaterResomoes ; Revised2,722016