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WELL CONSTRUCTION RECORD(GW-II For Internal Use Only:
I.Well Contractor information:
)&.�s 543 e q- E` { 14.WATERr.ONES _
JJ FttO%1 70 DESCRIPTION
WelContratttn`dank • Illy tr. too ft.
'j rt. , ft.
elg
11
\C Wed Contracio:Ctrit)cawe Nunit'ct iS.OUTER CASING Roe multi-cased welts)OR LINER 11f applicable)
L-c}lC¢ AOI" ct l t c- l '40iin • rnusr rT Tn ft. . nit MITER in. , IHICKNr:ss . 11I4TFRI.(I....
+°IP_—.- - (a 5 r'1 PVL
Cmnpxn\ ` 16. :NER CISiNG Olt TUBING(ueetbermal claed•ioopt
1 FROM TO L DISMETER THICKNESS i M.17E10.41.
2.Well Construction Permit a: h. it- ` p
tStall.alpta:htt ,u•tdtu't,ti,•:.ri pu t .a,i.h e L'1C'.Coants.Stale Variant eut t k i
ft. ft. I, In.
3.Well Use(check well use): r_
Water Supply Well: FROM TC1 t DiAMIETER SLOT MZC ' THICKNESS NATERIAT.
Agricultural [�\funicipa.VPublic R. ft. i. I
Cicothcrrnat Illeating'C:odtng Supply) Eilf otdcntiat 1Vater Supply wog...) I It. ft. i to. 1
industrialiCommctei;il []Residential\Nato Supply(*boreal '`-in.GROti.
tans To 1MAtERIM 1 11PLtCLML.T%E'f11OD&.A%int\'t
irrigation 1
Non-Water Supply Well: A_G I ifs. 'n'n l tie. 1 17 b)s
Monitoring URccovcry fr. ft. I
Injection%%ell: ft. I It.
a ar
Aquifer Recharge t,'.r.indw:ttcr Retncd.ation
4 !: 19.SANDtGRAWEL PACK(it applicable)
Ag)Itt[:!Sit and Rct°,en Eli •.._,ry Barrier i iRO1t f To i MAT'Mist I.MPI SC.EMI NT MEI Ron
w rter Drainage it• iL __.
Aquifer Test C3,., i
T.sperimentalTechnology 0 Subsidence Ctmtta'. tt. tt. 1
Cicothcmtal(Closed Loop) Q fracet 2D.DRILLING LOG numb additional sheets If nereruart)
mom TO Drst:RiPTIONfrolor_Sordoni.wtkrock �tp,t.,t ,tni5tOn.dca ._I
Geothermal Ilieathm}t-CoolintL Return) nOther(explain under a21 Remarks) . fr ft.
r1+� Well IDa ft. ; . Y it. r Gi
4.Date 11 elI(s)Completed:3l a�oyJ � -�� L'r�.._____ ....._�.--.R
, n. iCo rt. 1 LOC.-Cr 2,044,-
5a.Well tkatinn: --.--*----. _ — —._____. t
ft. ' � R' ,-- i rti _ _
}acihr 10v tar a a?sle) ft. ie.
Fas:tiq an ucr tin^u )' pP''� • � ----
C�WZ 5'�'(vae fi
fr. ft.
phy.i.al tdaLret..Cry,and 7tp -roasts
_._Pa .rcel... carp„-\, (Pro 1
Sb.Latitude and ksogltude in degreesitnittutesiseconds or decimal degrets:
err eta tieid.sr.,IV.long 1.•udlieieat) 22,Certification:
- 351c0s5 6ata9O C C.C c __. 9/a�fl3
6.Is(are)the nell(s)l/Perrwnent or DTcmporars
Srgaar' tiff Well C•,:it act.'r Late
9i a-.'tz h_, 11- V h that i, aril's.»a.it .s iii u n a r:.,.udan
7.is this a repair to an existing well: Yes or 'i ..rtl 154 VC 11 t. l t T'C dt•t( H frj 111 11 r.i,ova nxttra.Sand,...: s,l tk,,r;,
1l iliac n•a repmr,l'a out known%en r nntfruelino i5f omit tb'n and etpluin the non •:r rte t 'rt Pi iS.,rt. red h,::!... , ,,..:aa 1.tL• 1al P..i..
rrj.ur order 21 rctnnrkt tt'tttian ur on tic t.u..k or shot farm.
23.Site diagram or additional well details:
It.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the sonic You may use the hack of this page to provide additional well site details or well
construction,only i(1W-1 is needed. indicate TOTAL\l'MTER of wells construction detail. You In.ry rise attach additional page:it'necessary.
drilled:___._ 5U131,111TTALINSTRUCTIONS
j n
9.Total well depth below land surface: OSC
(fie) 24a. Tor All Rills: Suinr::tins tbrm Sothic 30 dots of completion of isdii
• I's.n:•„ri:1e•.ir)da bit ale depth.it dif c't f letnntpetr-3 q)fJD-Lind ib'fVT( epr5ctructio11 to the following:
10.Static water keel below top of casing: 5o (ft,) Division of Water Resources.information Processing Unit,
If.tat:,iced it n^nti cosine I..•.•" ' 1617 Mail Sarvice Canter,Raleigh,NC 27699-1617
11.Borehole diameter: (a (in.) 24b.For Injection Wells: in addition to sending the form to the address in 24a
tI �f above.also submit one copy of this toms within 30 days of cothnletion of well
12.Well construction method: Raba r f construction to the:aiming.
O e auger.ruraryy.:able.Ji.ectpu.h.cttr.d
DlsIsfon of WWaler Resources.Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1 1636 Mail Service Center.Raleigh,NC 27699-1636
13a.Yield(gptn) 10 Method of test: rre%Oit 24c.For Water SURD% &Injection Welly: In addition to sending the loon to
ir the addtess(es) above, also submit tine copy of this form within 30 days of
13b.Disinfection type: C i'"rD1 A t , Amount: cumplcuon of well construction to the county health department of the county
where constructed.
I.am i Cal'-1 North Carolina fkratr rent of Ennis.nmenW;Qu4111.y•Ditit:,,;r ufllater R:+osrc:. ftn»cd 2.22-2n16