GW1--00089_Well Construction - GW1_20231228

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For Intetowuse Only.
I1' Well.CrtIItLBCtoF IIIfetmatiOIL' -
Well ContractorName / ATERaEROlYt 0NF.5
TO DESCRIPTION
NC Well Contractor CertificatiollNumber 32 fk y' /
uT if4s m a rmnt&�ells 4'LINER.if & Ie '' 00 15 •y r 1 oI THICKNESS RATER/AL LComFanyhfame •
• f 11* I+SlR
2.Well.Cozis€I.?tctiotf Permit: 16.�`IeRChSTDIa oRzasnvG{.-.4.- „: closeddo.,1
List all applicable r well construction permits(i•�EliC Co Pia DIMMER. Tffie[avEssMATERIAL
� rmt4;stark Yati�aa elm) ft. ) j � Ia.
%j 3.Well Use(c11esr[veil use}:
Water Supply Well: V.SCREEN W i
1 A�tettltural I;,„cipaUPublic PROM Tp Jlurr,;,aya•� �orslzE
(3Cteothermaf(Aeatittp�Coolin Supply) ft. i� smrGravEss MArEn
, g PP Y) �►` 'esidential aNaterS�tpply(single)
• ‘ . Industrial(Commercial esidentisll aterSupply(shated) f� II t `a.
Irrigation is,GROOT it
i Non-Water apply Well:
motor To; NATEREAL EMPLACEMENT I©n&Ant
Monitoring Recov U ft- 'U ' VEr hp-e Ply" our
Aquifer Recharge' a
�CaoimHwaterRemediacFon fn Il i 1ir:
•
r 1 A4 fer Storage andRe ouery �'7Saiiai uttOrS SAND/GRAVEL vEL PACII'tifa tieable
ErY tyBaaier TO
DAquifer Testa tStonwaterDrainage ftRATER/AL EfyFI'LACEILiEly7 hIETgOL
f(; II
.i ?xperimenta1Tecbnolagy ISubsidenceCon[rot f[; ( etsthermal(Closed Loop) Tracer I +�
, Geothe[mal(Heating/CooliogRe6o¢n} ©the IN GIMG{ 6'td0�6on�sheetsifnecfssary
i Cexlainunder#1 Remarks) mow Tto; DEscalirrmN tca[ar haraness.saatmctc "rota gze,
• ft..
ly
=°-Dateweli(s)Completed: _ ' Z3 Well KW 3 f, poi- act r.,t•�e/
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f; Sa.QYe11Y,otxtlon: I Affe c. �„`
fr; rAv-ery awe f/! ft.
? F¢cilitylOwncrNamc F
�U �`�� Facility ID*ffaPPlicable) ft. 1 ft
�ti i et oar ,Chi and P ib�'f s y �� (.�l�cce Vv ��� q 3 �7 " u, ,
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- County - - g
Parecllde daatiouNo.(PIN) f I i , "",7,7,1i.:n ;'D,•
sb.E,atitnde aDdioauitade i n degrees/minuteslseconds or d ^^^ ':•`4
ii' "tdh,•,yi
, CFwelt fte d,Gs&Iatflaagissnffcientl �degrees: (
:±!' ,`ae S(.53611G r -Certlfrca :
ji 6.Is(are)theweII(s)¢►gin•ermttnelit or Temporazy SignatoreofCertifidd Welt tractor Date �3
1.1S thi&azeAair to an esist'utg�vell. eS or By sigaing this faint,L hereby eerefp that the neli(4 war(wtze},construrled is ace
I1;`. !Phis `'` sok 1Sg a C-QZOdot•1SgNL'fiCO2C.02Q0IYellCoasurrctioaStandardsaz
' ,i„ ruelionit�Jormp/iotraadesplitketheaatrana�Ylre mPP�dds i beeicproyidrtltathenalFmmer
1 ,€ repair under i l remarks section or au the hackafthisfann
' 23.Site diagram or�additional well details:
' { I.For Geaprobei pT or Closed Loop Geothelm eWeiisbavingthesame Younrayi ao attack of this page to
i , - construction,only I ti-W-1 is needed.Indicate TO}TlAI, (tweakconstruction de '' P i; Provide additional well site details
'�': drilled:
Four may also attach additional pages i€necessary. -
:is •
9.'Fatat well depth below land swd$ee: I PtS N TAx._._. IICIT�NS
I., Forarukiplewel/s list all depths rfcli erect(example-3®20p'ond2QIl70) - at) �'�'or---Wells: Submit this foB1t
�'+� construction totli'ftiliotving; within 30 days of completion
i 10.Stlrficivater level below top of casi�a: •
110 ( ) ;
j 'Jjii�tee•level is above casirtg,ulse f 1)ivisiof�V`aterResonrces,InformationProcessir[gIT>
t:'' ll.Borehole diameter: (� / I Service Center,RaI
''` (ro e+g$1Yt;276994617
'241r-for TnieMi{on'Qpel)s: In arldition to setidmg the fnmi-to the address
1 I;` k2.Weliconstiuc€ioa method: d` above,also subs_,one copy of this foan within 30 days of completion
' FOR WATER SUPPLY' I
©Nj,y. Aivisionof�EaterRl urces,IInte Raleigh,
(' 1616 Nfaii�Service Center,Raleigh,NC276991.636
', i; 13a.Yield(g¢m) 1VFetihod ofLest: f �.d 7
{' ?4a Tor Water__max__&Inieetiou Wells: in addition to sending the:
i' {) 13b.Disinfection type: H H 2 d� the addresses)above, also submit one copy of thfc farm
Awnanir completion of werll cons action to'the co 3h e
III ! whereconslructer- 'BealrTt department of the
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