GW1--00085_Well Construction - GW1_20231228

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For Irtemhi Use Only:•
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1.Well Contractor Information:
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Well ConnactorName 14.WATER/O i
qq MOM. ATO I ' DESCRIPTION
j: _ fJ ZS�rt Ya P)'- 'frj C 40%• ;I NCIVeII Contractor Certification Number
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II Dv (� (� �t j � ]S.OITTtsZ.es.sNG formate-cased wells OR LINER a..I/cable
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',{' FROM ITO. DIAMETER TEtLTtTIn�C
t{ Company Name D /MATERIAL
� 2.Well CoDSIrucijon permit it:3 S 7$3 16.IMZ;R.CASING ORTUPOIG •..the S PR'Z b
Listallaoplicnfileivellconstructionpermirs(i.e. FROM i}6 { dosed-lob.l
' DFAl THICKNESS
q$� f u3G Counrl;state,Variance.etc.) It ft. in.
MATERIAL
1 3.Well Use(cheskwelluse), IR
1I " tt.j WsferSupply Well:
i7.3eRft` I i
ill mom To • DIAMETER SLOrsr :
Tffi s nATEgAgrlcuiitrai ...cipai/Public 'Geothermal(Heatng/Coolin Supply) Xv,. identiaYWater So 1 I ' N Industrial/Commercial PP Y(single) it'(Residential WaterSn 1IMI in.
Frri lion Supply(shared) 18 GROQT i
;i Non--Water Supply Well: >?aar�' TO yra2nurtr
EMPLACEMENT M TTIOD&AM
„Montt eiug Recovery il 12 P It' 3/g de- OMi Ir. I it
Injection Well:
Aquifer Recharge DGrouudwaterRemediation I i ft.
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A4uifer Storage andRecovery oSalinity BonierS6IVDIGRAtrLLPRG'Sfifa. IIcable
Aquifer Test PROM TO i MATERIAL
StormsvaterDrainage g, EhFPLACEittENTi4iETHOt
i .Experimental Technology I ff.
1 • iSubsidence Control t., ft
ir `Geothermal(Closed Loop) �ITracer
i Geothemmal(Heating/Coo-Frog 20.DRII,I.7l1+OLOG(attach additional sheets it:necesser•V
CooTmgReturn) _ Other(explainnnder#•21Remarks MOM TO • DESCRIPTION Cw[orhardaess son/rock aorain size
4.Date Well(s)Completed: /`p W2 3 Well min 5 ,
i; '00 ft. r
5a.WeilLosatiou: it: I
An/
Line-be r ft: :
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Z ��d'a� R Tca�Gr�orG actlitp [ ap Gcabte) ft. ft.
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ft.
o.--,, ti .4.,,. ..
�, Physical Address,City and Zip
Y� eh,___ ____________ � I 1 ft. a
'' 1 00_03370 / 21.Rn1 ,j - = c3
►Y • Parcel IdentlfirationNo.(PIN)
II I :;,r0.' ,�"'� .y•
Sb.Latitude and longitude in degrees/min' utteslseconds or decimal degrees: I rJ?:;.(•.;`F is ,
. Ct wclt field,GA lat/tong is sufficient)
W
11, 3 G, 3/ Ig3 N S 2�11�i 22.Cert;lie
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II 6.Is(are)thewell(s) rmanent or emporary SiPnatmaofce 1ed , Date r
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S' r,; 4
1; 7.IS this a repair to an a s#ingrtyell_ yJes or By signing rhfsfonn;l het eby certify that the well(s)was(were)-constnrcted in acc
J7.Is is a re air to an exist ingwell: o wig:ISANCRC 02aropO or ZSANOW 02C.0200 Well Constnrctian Standards az
tttforrntuiotrmt$esploinrFrenaauzoftlte ?Poftlrisrerorrisheettpravidedtotlrenrllonmer
!fails
seer a r,:::::driamo:
fill
cnitnown orsthehackofthisform .Site diagram or additional Nell details:
2.Fur Geepred Loop Geothermal Welishaving the same y use the back of this page to
You sira provide additional well site details
, ; construction,only 1 GW-1 is needed Indicate TOTAL NUMBER o£welts construction detritus.Yon may also attach additional pages ifnecessary. •
1;i dulled
} St3131►DTTAI,lb/ TRUCTIONS
;: 9.Total well depth below land surface: 500
" t,- For multiple wellslrstabeloifd,ffereat(erample- andg ( )
4depths (a3100� 24a.For We s. Snbruit this form within 30 days of completion
i 10.Statii:�vater level below top of casing:37 construction to the`Folio�ving;
I' ( } I
{. Ij:taterlevetisabovecasingrrre�" Division bfWaterResources,InformationProeessillglJnit;
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i I57MarZ per vice Center,12alei
71.Rorehole diameter: �� 9 s gh,NC 27699-1617
j. a 24b.For 7nlection 11 s: ID addition to sending the form-to the address
. ..1
2.Well consist roar method: 1 f !1p G above;also subtait one copy of this form within 30 days of completion
1 (ie.augeSmtaty,cable,duectpush,etc.) — constractioAtOtitre ltpyvjrg
1 FOR WATER SUPPLY i
WELLS OAILX Division of WatetiResonrees,Undergroundl'gjeetion Controlprogr
:� 13a.Yield(gpm) I �m1 16(36 Mail Service Center,Raleigh,NC 276991636
Method of test:A ! 24c.For Water 8iltanIV&7niection Wells:
,1 ly I3b.Dislnfeetitra type: d' In the address(es) abo addition to sending the
I s' Amount: QZ completion of wall'obstruction also sahmit tine copy of this ern;within th c
onstructioa to the county heaIih department of the
where constructed.