GW1--05892_Well Construction - GW1_20230918

1.w I Contract ri InformaAJbe
on
It C ( �+xtret:�,oiu��PROSE TO -u�aa�nt�i,o�r -i-�..i -.
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NC Corns Cenigatlo'Nomber
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• 2.Well Construction Permit* . L
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Lls tall app►icaldeueUronrwedanpernhs tie WC Carry.Saw,Variance.ern.)- fa •" t► �•
3.Well Use(channel!use): . _ tr. e: fa.
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FROM TO DIMMER. S1OTSirs TWCRIIFSS^MATER/AL -
jAgdcuttumi QAMWncipeliPubha O tt. ft.
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in Geothermal(HentingoolingSupply) DEsidntiel Water Supply(single) tr. it to : ..
jIMuahiat(Commereial - DResideatial Water Supply,(sharod) - _ _ -
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:Irrigation V PROM To Y MATERIAL-�- IMIIT LRE!SSNTMt?rHODetAatOtNVT •
Noa.Water Supply Won: 0 D. VC," �•ti,I?'i vc ,igt.t t m.,t t •
"d nito inn Recov
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AquiferTest -- inStorrowater Drainage- - - - --n ic '
Txperitnentel Technology DSubsideaee Control . ft it •
Geothermal(Cloud Loop),.. DTraeer '10:n�ti;ilea•I:fltS riiiit iwmi diebiatiticimiiW4=��� ="t-ei - .
neeo :awl(lirdting/CaolirigRemra) Daher(mgeetnunder#21Remmers) =Oac To DESDIIPrtoat(calm u. ,00l ttp..,u.enta,etot
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• 4.Dale Well(s)Completed:j-)3-) Well1Dtt,; I' >� /�G tt' SG-TT &a'c
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52.Well Location L.''✓ft. 3 c/f f 0 •-"",•r r/<"t`'
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(tip➢ttreble) tt I i C:- i 1 j ..
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Sb.Latitude and longitude b degrceslminuteslseconds or decimal degrees:
Orwell Held.ono Wong tasufficient) 22.Certification: " D�,4 g a- ,13
.2sQ�/o3 9 H 'J' 3 a w A .be au,teivA
6.is(are)thewett(s)aPermenent or [Temporary y, SignrtoreoC4eai6ed WellCoanctor Duo •
Bysigdeg rids farm.I hereby car*Una the tiell(t)tar&ere)contovcrd at accordance
• e 7.Is ibis a repair to AD minting well: ❑Ye+ or o wish lid MAC 02CA100 or L5AMeC 02C.020 nnoa 0 SW Canru Sfa iardr and that a
f1dr4arepatr.Jllloidlrrmarwdfcentrrucriarrinfarastua,mrdetp/mn/haMaraDfthe 0:IPYofretsromlembseupl w ldtothelil ,awnen
repnirendert21 nmarbaction ar antes hack oftldsfarm, '
23.Site diagram or additional well details:. -
• B.For Geoprobe/DPT or Closed•Loop Geothermal Wells having tbesumo You may use the back of do page to provide additional Intl site details or well
- construction,only 1OWIisneeded.Indigo TOTAIMUMBHIt of nein con sttuctiondetaps.You may also Mach edditional pages ifnecessary. •
drilled r,� SUBMITTAL IP(ST1ttlCTYQ I$
9.Total well depth belotrlandsurface' 1 ` (A.) 2ca,Far MI Wells: Submit this fora within 30 days of completion of well
heawfaieemellr(vtdldepnccifeblrat(emmple.3 aa•aAd2@ld8') commotion tothe lnllowittg: •
/
- 10.Static water level below top of casing: (rl'0 (IL) Division of Water Resources,Information Processing Unit;
1/warerl reining uu+j" min Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 113 I44 ((IL)• ) Z4I For iniecttowWellst to addition to sending the Ammo the address in 244a
12.Well construction method: P()'�A Y' { - above,also submit ear copy of this than within 30 days of completion of well .
Cw mei.rotary.cable,divot put%do.) construction to the follotvmg
.
FOR WATER SUPPLY WELTS ONLY: Milton of Water Resource;Undergr
ound Injection Control Program,
/�� lk�& / 1636 Mail Service Center,1Raleigh,NC 27699-1636 .
13a.Yield(gpin) I Method of teen_fO.ptr..1„o" 24e.For Water Sunnty&infection Wells: la addition to sending the form to
�/ the address(es)ahoy; also submit ohe copy of this.tens within 30 days of
13h.Disinfection type: rill t! Amount: / C7S completion of well construction to the cotmty health department of the county
wherecenatructed.
FatmGW-1 HaabCaiotiocD atEndronEen 1
qutsmeat _ �3Qoality-DivisioaoflYatuRraomer� Rorirod?r2Z2016'
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