GW1--06704_Well Construction - GW1_20231024

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1.W 1 Contract; Iuformat1 • - -
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2.Well Construction Permit ill. � ...ah �• IAL
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3.Well Use(cbecktrell use): it n, to
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QMunicip8I Public 0 Ik tLtCKNpSS^ MATERIAL• .
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? ..thrmal(EmGn lCOoIingSupj ) O Redd eatalWater Supply(sMee)
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Irrigation TERM 70 . .,4...•. ._r : .t_r��::.:: s. ;y ;,,,,,;.,,
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• Ill Aquifer Recharge OGroundwaterRemediation ft.
in AquiferStotageandRecovery QSalimlyHaaarr �ieRiE iirmIGRAIsEP deal TE arAL I6tbr�' :—t-:�-•- �, _ .
II Aquifer Test T±ROEsr TO MATERIAL FtglrACrarEttr titCffiOD
OStmmwater Drainage !ti it
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•Experimental Technology OSubsidenceControl m tr.
Geothermal(Closed Loop):, OTmeer- - Fatvo (1•IAG'(eitr"ds ntidltiiaieihtie'ets :"'iii". ' -
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_Ceodtermal(IleatinPfCooliiigRenua) D�a(a4lainrtader#2lRemada} Y
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4.Date Well(s)Complet •- Well IDd. •d 95 it e''r,v e- /mac
Se.Well Location: Y. -it ye • 6 n, -c 77<
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BacdilylOttaerName r" 7-4 T-, ,2l3,.. ,_
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ConaQr patealld t:at*taaNa(PIN) -;�,�.;S:+Z(;• "%_
Sb.Latitude and longitude in degree drab: tes/seconds or decimal degrees:
(ifweuBeld.aaa6rRanghssuffi/ciieent) 6 a- 't
S, Ga S/4 �/ 22.Certification:
Ai
• aidgd 70_/- „?f
6,Is(arc)IbeWell(s)I [�
Permeneat or Temporgry SigoirmeaC2emfed Well Contractor c �r
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1.Is this a re � Bytoping this Join%I hereby ea*that tit;WO) t aw)coastnural Di ocrordonee• pair to an taming well: OYes or i JL'o with 1.taatCO2C.0180 or lie!J 02C.0200 WellCmmnroion&we're,and thata
gthis tut repal,fNlwnkrmarwdteauunaiorrtnfcncrmn mid eoplatnrhrr what Ode mFyofrhu mold has bun prateted10eel*Icomm repa r:We,021'worki:eaten mon the bathphufan _
23.Site diagram or additional will details: •
S.For GeoprobelDl?T or Closed•Loop Geothermal Wells having gleaning
You may use ute back of thin page to pwvidc addldaml well site dtxaas ors Well
canstntctlon,only l GW 1 is needed.Indicate TOTAL NUMBER of wells consdurliondetails.You may also attach additional pages ifne cer ny.
Millet
L SUBMITTAL INSTRUCLIS �S •
4.Total well depth below iandeurfarxs l G�
- _ —bbsmaWptexetrstwaldep ldgjve„r(ec�ls•1�0o•a„d2 ,fl0) (h') 34a For MI Well;: Submit this form within 30 days oPcompletion of well
construction to the tnllawing
10.Static wage-levet below top of casket Ce, (rt,) Division orWaterReso
Ifwarerlewl Uoboreeasing use-4." urea,Information Processing Vail;
!/ 1617 flail Semites Cebters Raleigh,NC276994617 •
11.Borehole diameter. (tn.)
n 246 ForNeutron Welly in addition to sending the famrto the addax;in 24a
12.Well construction method: /`O Ct-r y ( above,also submit one copy of this ibmi within 30 days of completion of well
(�age.Mary.cab!;Cuedpwb.eta) Gf��l construction to dm follow
FQR WATER SUPPLY WELLS ONLY Divisianaf Water Resources,Varlet:ooponyd Inject on Contl of Pogrom,
the
// c 1636 Moil Service Centel•, alcigb,NC 276991636
130.Yield(gptn) 7� Method oftest �.nL�l�tl� For Water Sunnty 6k Infection We ;: Ia addition to s/� I t" ending the form to
• 136.Ditlnfeetlon type: `f l f 3 G y�j ad s(os)above,alsosubmitone of this form Wlthia 30 flays of
Amonm: completion of well construction to the county health department of the county
vrhera¢ottt:tlUeted
Form GW 1 North CmolmnDeputmeeteiTatimnmentd gnarly-Division ofWatuRcstaato+ tiavletd2-22.2016'