GW1--00095_Well Construction - GW1_20231228

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Well For Int Use Only_ -
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ell.Contractor Information:
:/,ef N.Wig
Well ✓ (CONES I
we
ERONL TO I DESCRIPTION
. C� � 107 ft.
ag If R granth%til
NC well Contractor cation Number 70 tT. 1`1
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]5.OUTER.tiiASING for Eligrai,'I'1
t © 1� rf( /�! MOM ���ctsedwetis ORLIHIrA tfa•.11cabTe
!' Company Name D I DIMMER THICKNESS AFATEAIAL
it: G in.
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2.WellConsifi+IctionPermiti�: 'bs ,
1RONE EIZtIITO ORTtIBllcll^:.f_ thermal THICKNESS
List all applicable well conntruation permits(i.�IIIC Coantl;State,Patumc�elation `Ta DFhhI> t TBICiCNE55 9iA Rt6T
3.Wen Use(eltesl w eWine): 1
,t: Wafer Supply Well:
CI in.
1; 17.SC[REEnt II
I Agricultural PROM zo , �,.� ,•a
:i Geotherma!(Ileating/Coolin Su I pallPublic ft' ® sLoxsrcE rm sS mr�xss
g FP Yj idential Water Supply(single) _
k Inclustrial(Comnlcrcial i� ia. __
[Residential Water Supply(shared)
11 Ind tion i8.GROAT 61 i
Pion-Water Supply Well: O ! MATERIAL
fr.
SNPLnCEnnaME•THOD&AM
Monitoring IX° lt' 'irk '1 P Xol
Injection Well: Recovery
Aquifer Recharge DGroundwaterRemediation
Acmifer Storage and Recovery CISalinity Bauder 5A1VDlC*$eLVEL PACE(tf a• livable
;i Aquifer Test
Ont To , MATERIALOIStomtwaterDrainage ft EM1fPLACEitiEKT i4IETHOx
Experimental Technology I ff.
�►Subsidepce Contra)
I Geothermal(Closed Loop) ITracer
Geothetmat 20.DRIFLWGLOGfa h.additioaaisheets7necessar4
(Heating/CoolingRetom) ,©ther(explainunder#21 Remarks} >:x N 'n! 1
DESCRIPIT+Pl War.Iambuss sailtmckty c.main she
-DateWeII(sj Completed:G7'3��Z3 O frZ it. , 4,�A
---------__ Well
Sa.ilYellLoration: Q 3Op it f
_ nl9� F&q
fey Sahch�z
' EacLty/OcvncrName -�
FacitttplD, (ifapplicable)
11` W71 S(ancl o J Cry /ec CZa �
PhysicalAddress.cit and T.r'p Lf �<T `_ ,_
933
I. county RmiallKs. 0 ' �«
Parcel Fdenfi6eation.'No.(PIN) a
IF' 5b.l atitudeand longitude indegteesluiinntes/secondso I 1 .!
u:,wr,-T r, r�{; . (lfwcf find,91it latticing insufficient) r decimal degrees: 1 ��.^^�
'�' 3G.�j 7• 7� x ��t �� !a z2.Certificatial�1 ,V w Ljg4':Fst i 6r.
/ .a
eP� 11 .
` II 1 G.Is(are)the wells)I Fertaanent or G7-3/-23
j +QlTemporary Signature cifCertiffe&IWell aaetor Date
7.1s this arepair to an esistingwell: El7les or BY signing this for'mJ l;hereby certfy that thewell(S)ell(s)war(�vcse.
I in Ifthisisarenafrfdlout(arawn:veAconstruelioxipJarmWionmrcj O ructed in ace
with ISgNCrtCQ3C�.Q100orIS:€NC�1CO2C.020D Well ConsrrJrrerinntStandards or•
repairnnder;121remarkssectionoreadiehackofthisform � llreneta�o the �pPa}this
' '�; r?cor Isbeenp>avidetlprtlre��vllmvner
• 4' 23.Site diagtnut or additional
;,i S.For Geoprobe/DPT or Closed Loop Geothermal Weltshavin the samemay :leek of thispageltoe�IIs:
I j; construction,only I GW=1 is needed. Indicate TO You provide additional well site details
I dlilted .i�tIIMBERofwells construction d " Ton ma
• Y also attach additional gabs if necessary.
9.Total well depth helowiaadsurface: 1 EI'TALglSTRUCTIONS
�'i'` 9.Total ewedspth below
land
surface:
(example-3@ZQO•ar_2 00 ( )
G I ' 0. 24a.Fore: Sultmit this farm within 30
u/� construction to ttie)allowing: days of completion
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u i 10.Statiewater level below top of casing: —t
1 i t lfirate�level i-water
level
easing use" ( ) D3visi�n l f 4Yater Resources,TnformafioII Processing
Unit
II-Borehole diameter. �Fl 17 iI Service Center,Raleigh,gh,NC 27699-I617
' ',I -•24b.For Tnieafei Wens: la addition to sendmgthe form-to the address
' (i.Well construction lop method: C O above a7sa submit a copy of this form within 30 days of completion
G i [s e.augeymtary,cabl
e,directpash,etc.)
t 6
!,I 1, construction to the foliowm*
FOR WATER SUPPLY WELLS OOYLX Dit7siolt of Watl rResoarces,Underground
'� 1i Injection Control Progr
13a.Yield(gpinj 25 - l.( 1636 Mail Service Center,Raleigh,PIC 276991636
•
I I .y Method of test: / L,t_ 24c.For Water
136.Disinfeefian type: 1 C( �pppIy �iection spells: In addition to sendin
Amaant: 7 the address(es) ahoye,' also'submit one copy of thus form g the
completion of well construction to the countyhealth thh 30 c
where coasttucte� department of the
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