GW1-2021-00052_Well Construction - GW1_20211109

1.��ell 1.0111 rail:,r:u,o,wa„o,.• I I
G��`` IJ.N'A'I'F:R ZONES I
l t �� FRU%t TO DF.SCRIPTIO\
Well Contractor Na.::r 6 ft. I 60 ft. HD 6z,
I
`f Oq3' 2oo r:. ' 366 ft, i I low
NC Well Contra,.•: em:lzat6,n Nund+c IS.OUTER CASING for multi-cased wells OR Lf\ER Cda licable
yy. 1 FROM TO DIAMETER' TIiICK\ECS MATERIAL
(�WyJ1/�CS2 St �\ ft. ft. jin•
Comp nm Name 16.INNER CASING ORTL'BING othermnl Closed-loo
FROM : TO ' DIAMF:1'ER " THI(,Ii�\FSS MATERIAL
2.Well Construclion Permit 4. b ft. 5z ft. • -I in;
r I'r',t'wau:..�lurc•.1'in•nrn,r.r1r., ! Jl
l.nr till appli;vblt ,nvrh,nl p,9s1>�..+L%', !
ft. ft. in.
-------------
3.Well i se tche:ic%Neil use): 17 SCRFEN
VI'ater Suppy'M ell: FROM TO DIAMETER SLOT SIZE TNIC'K\ESS MATERIAL
Agn.u'turai ®Mu is oa 1public fr. I in.
Geotherma:t i t:.^.::r.L Cooling Supnl\'I esidential Water Supply(single) f;, i fr is i I
Industrial/Colr..:aa...! ®Residentlal Water tiupph ishared) I I&GROUT
FROM ! TO i MATERIAL EMPLACE�tENTMETHOD&A.MOUNT
lrr1i2a1iJ11 i f„ Zc ft. d f/f K
a[Cr SUP16 %l rile
yAonitonnz Reco\.er\-
ft. fr. !
Injection«'e14 ft. I ft.
-�1Ci nund\\atcr Remediauon !
Agn:erRech: I'J 19.SANWGRAVELPACK ifa licable
Aquifer Stora_::,::.i i.eeOvery
®Salinity Ratner FROM TO aATERIAL E:>1PLACENfEVTKEfHOD
Aqw!: r lest
©Storm+%ater Drainage +' ft.
Experimental >•o_) rISubsidenec Contra!
ft.
20.DRILLING LOG(attach additional sheets if necessa ')
Geo:P,ern al I:'•+; i.,•tP i Tracer DESCRIPTION Icolon hardnes+.soiL'roet tv e. rain size.etc.
Geothermal i i " Dull^e Re' t i Other(cxplunl under�^1 Remarks) Fv vt r.. T5 Z ft. i `+,Q ! Q r
4.Date Well(s)C omctteteG; IO 13-2 l Well IDk 5 G yQ
5a.Well Locati. ... - - -�
t'c. ft. '
MOM"[ 00120N
Faciliq C1%%ntr\; Facili;) ID=1tt:lpplicable)
ft.
ft. ! JC
Ph)swai.lddress.,......,;.:lip I
r `��^g, : 21.1tENt�R1�S
Mad•Sos+ �-=� l
Counq Parcel Identification No.(P]N:
5b.Latitude an._mi; T.udc in de'orces%minutes/seconds or decimal degrees: 222 Certification:
IifNeellfitld.rna;-. . sufiicttnn
35�4�1 g•5g SZ°29° 2o . Fsn142o �� _ _ A)-/3-1J
natuttiai Well Contr,oi Date
6.Is(are)the%%c,:,. erutare,,, or Temporary
Bt ,r;;nnr. : "lurnr,l Ger,•h, :rruir rlrar rA;uah.v u•a., hrrr:,:anrin;ded m uc•ordnnce
misting%v c'l: ON-es or ', o_l .u/!Iu or 15:1 t;'.it'tilt' a:uo I:'rh Conv/1•e;1mn Sralldurd,and Iha1 a
7.Is this a rep:+ .op,•n11/,:'ri.I•rrl h"heop pr 'We4hi Ihi•Nr.91.':'r1.•+•.
I/rhi..1, :.purr.• . ,'.,1,r.•O,+,avruruonrliturnarlu,p;nrl,:rf>GIwfluuanrrralrh: I
repair mid:r '/ ..u,,a or tin tlrr h,r:k al da.N loan. 23.Site diagram or additional well details:
You i%p. .:se the back of this pace to provide additional%%-e!I site details or well
8.For Geoprobe 1)),i or Closed-Loop Geothermal Wells having Ine same C;,tlsu'uc;.,a:detail;.:You may also attach additional page,ifnecessary.
construction.or, :s needed Indicate TOTAL Nl:vlBi:R ofwelis
driiled: SV BNIITI Al.INSTRUcriONS
9.Total well del„n n:::m(and surface: � (M) 24a. For .ill Wells: SDi\mit this form within 3(i days of completion of well
l•i,r uudlrpli•ur//,r ^„r;r.r;Jr;r; .d•:r,ngpA•-:ri::bU .aul_'a,lull') ,:onstruct..,n zo the ibllu\ving:
10.Static water 1 i low top u'rasing: 1);vision of Water Resources.Information Processing Unit,
If,na;r 1.,r/1,:,r• •. ^'' 1617)tail Sen ice Center.Raleigh,NC 27699-1617
11.Borehole di:arl :: /o• (in.) 241). For-Li �i'ells: in ii'diuor,to sending the form to the address in 24a
�� ahitvc.a::,t sabinu one copy of ibis loan \\tihir.30 days of completion of well
12.N'cU constr....:r,.::itetno ennstruc:•r,w rite tollov:m_:
Ii.c auger.rotar,... .. _._-::push..::
1)ivisi„n of Water Resources;l"nderground injection Control Program,
FOR�t A1't:R • ::t.. «Ia.(.�t s�l.l': 1636 Mail Service!Cemcr.Raleigh,NC 27699-1636
13a.field(gpr.•, Method of test: �•
1 24c. For N%ater Sunnh'd Iniection 1\"ells: In addi:um to sending the form to
�"1 ,he addr�.,•es) abo%'e. also summ� one coay of dtib form WitFir, 30 days of
Cr1lOY1�Q .Amount' +1ft10S eol»plett. Jf%veil construction`to tile m
e county health department of the county
13b.Disinfectio -- m%%acre co.)>:ructed.
:..i. \:,ah�'araZ:n::. :p.:rrtrr....Fn%:.a,:nkr,t.+ ;fiat:, 7r...,•a...'.\.,,.r R. ,.:r''r.
-kc.;sed'_22-2016
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