GW1--06813_Well Construction - GW1_20241114

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. • Ptini'•Farm,•-•;:
�NSi1Ti�TZ®1NCORIID(Q g1 For Internal use Only; ':•
1.Well°Minstar Snformatiou: •
•Gary.Thompson - 111 •
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Wall ContmetortVaoro _ • FROM Mk - DFst�ION. ,
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. • ' 15:OUTBRCASING(litrdaltkos�welb)ORL1NPA'6f&p- ).:•- .' ,.:.•.
Aqua Drill, Inc. .• •enna: 70 DIMMER T riZ'• um%
:Compaq,Name• O ft' i CIS IL I 6'(Li ISDRat pV C
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R L Well Construction Permit* C WIWW-a 4O y-00 8 FROM to ntaarert3t ,•�, ,;List all applfeablcu a consaveilanpermi �WC;County.State.Ymioiwi me) ft R in.
3.Weli Use(cherkwell use): ft I ft in.
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Water Supply With 17'SCRSER:. .
griadbnal golimicipidtPubffe
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eothennal(ReatingCoolrngY) esidtmtialwa Water Supply
mom PO ft DA1fElPIns
�Lln� raiesswas—
ft.• 6 Ia.
Residential
Water S
iRation upP Y(sh „a GROUT.. . ,• >. :.. ..—...• . f: r .• .:. -
Non-Water Supply anon TO aLA� ifimrsc�mierazantoriaamOurrr'-
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pPlfwell: O ft n a sertivoi,t1 w.f }•e
• mitering • pReco ► fa & Pour}
jeclioo Weli:
ElGroandwaterRemeation - - ft ft.
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Aqut�Stotageend Recovery -15LSAND/GRAVE.pecS mffeab a
T E3SaliwtyBmmer FROM I to
• Aquifer Test a„mu • 71 5� •
StamRvaterDminage ft
E1nperimentalTechnology DSubsideneuCmdml ft D.
MGeothennel(Closed Loop) DT • 'z.1MILLINGLt1G(attdchaddltio=stake sif
riGenthennel(HeatmglCoolmgReam) f Other(enpleiranderfEl Rem ill) EOM - " macarrnorrrac r. ereemnrAdosm*a.asnt
4.Date Welke)Completed: 11-L1-'a,�l 0 9b .k II r
WeDD1U 10 ' 90 $, Setn A ece k- , '
9a..weR Location: 90' tz PIS f6 Q I ul (i rani <
Plosion noiv es of Greensboeo clS ft aa.S fl Sl u e (.-rr.:n i 1 t
Faeility&OnnerNmao . • -Balky Wig(fepal:able) ft tt
0til S CwA,,Ineela ea. Ee i els�ti Ile uG 2 320 _ __ b "F
PhyalmlAddaeee.�.=dr* . ,.'k.:h �,a,?_.
Rom;.Ki noJlr,ar� 21.=Imr s . . : • 1 j \ I "::2024. . _
Canty Parra hicarithationNo.00D
56l,atitudeand .- ..,`-••••. -
Gf langglhrdeiadegr+;es/mi oteskeeondaordecimaldegrees: jr '::'
3�o1.41461 Rang�soffekn)11T �9D 3 s 22.0 tIoir: i •
f r:
dy9. � w i.
6.Ware)thowal(s) Permancot or DTemporary. `�- -ay
stitaeemof van e
7,i,lids arepait•[oaoIV signing ddsf,m,,I trerrly dart doe nags)was(wadconseuaealm am da>tne
i1so existingwdD es or No vrhl3ANC 02C.0iI0arISANCACO2C.02OOWMCamaaWonSmadardsmtd that a • •
. r+ rsexanEr orandiebatam la I cf�ildfams. tromaftke �pYofdrtsmeordirarBecst Provided taflramdioumr.
23t.Site diagram orndtGtioaal well dotage.
. 11.For GcoprohdDPl'or GasdljLaop Geothetnl Wells havin thesame You�Y use the back ofthis
construction,only LOW-1 isms.Intricate TOTALNUMB/of:Ifs• ca n details. You may og000ttach additimtal well she dy . ar we11
Mkt
P��necessm)..
• SUBMITTAL11VbTRIICITOMS •
,
9.Total well depth helots hand surface: ' OM 2Aa.Pot MI Walla Submit this form within 30
For multOleoel Arian dapthsrdee=(esampfe-330-4Z
•andK)JGD'1 days of completion of we11
cotdsduetion to the folh►wiag
IR static coats level below top ofeosings 4 •
go Division orwai�er Bao>ur .IOfarmaHaa Processing Unit, •
llw eaukrrllsa6are "� • 1d7 Moil Service Center;Raleigh,NC2769M617
IL Ecsehete diameter: O (in.)
246 For_Inieation Wells: In addition to sending the form to the addiess in 24a
• IL well construction mdhod: rt.0oYr1 iC . above.also submit one copy of this tbna within 30 days of completion of well
(le.=gensa y,e rmialush,era) consauctontothefollowiOg
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Welton Control Program,
I636 Mail Service Center;Raleigh,NC27699-1636 •
' .13n.,Y(eid Wm) SO ' Meshed otter Co.t G h +T j 04-24c.For Water Sanely&Infection Wells; In addition to sending the form to
.13b.1Nslmit8ctlao type: 1�1'f H��.�e the�(es)above,also submit ofie�copy of ibis Rum within 30 days of
, Amount l 4 o t completion of nail construction to the county health department of tha county
where constructed.
roan GW 1 NanhCsvlinaDepamomntofEnvimnmemal Qualls, o�-DivisianoFWaterResouw tievieed2132.2016
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