GW1-2022-01137_Well Construction - GW1_20220103

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WELL CONSTRUCTION RECORD fGW-1) For Internal use Only i
llti F s,.
1.Well Contractor Inn. Ilitin:
f4 ZONES .t>€.. ' a
IVcil t bntiaetttr h V FROM TO m ta1P7'toN,
ft.
9L j� n. tl.
RC Nell Cornowtor Con,tication Number. 13=ti 3i,l ' tir�{tn
at"'lMe11'.)121 IE� ifs 9tcshl"}
1::� 1' FROM if) ttt.i.41h`:trN `.tYtIC1.Y'r;s9 MAI NIAl.
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Ctsn>f{any unto
CA lv 0111r G %cotttcrmi"'Idosed t"
:2.WellConstructionPermitit � �� Jfrl FROM IY) _, atnM>�rFx aftsnk s +>�rENut
d.tst rrll apphrgble urtt e'otlstrteCt£t5n r e rntets fi.e VIC,C nunn.State";i nrrrr.tcr.,etej' ft• € f t in
3.Well Use(checkavell use):
1M1'atcr Supply Well: FROM TO :DtANKFI'R'N SLOTbiZE Ttntt:nt sS:; ATF,RtaL
f��*rlCUlltlrtil ': �3 h'IUn1Clp"t[tPt}hhC -.. tl, ft. tti.
Geotltenval'Heatinit(Cooling Supply) estdCo I ldatrl Saii�ily(single) ft. ft. ^
1ndustrialrConnnercial OResidential Water Supply(shared)
hti ltit7n 1 nt)nt - 1'© 31ATFRIA1 Fh1rt,At 3FdNr. 7d1t:TH01)t;4#IOLMI' .:;
�tnt-«lacer St�plt�Wt_Ils�_�. ,.:
Monitoring Rctovray +++���
Injection Well: __..._ _ - rj1P
tt ! ft.
:Aquifer Recharge- 3Ground%voter Remediatior,
Aquifc r S{otttgc t+tfd Rccovrri Dialinity Bonier Mcinl TO MATERIAL E�i�i ncr tit v t R�trttt)n
Aquifer Test tonnwatmDrainatle i ft 7i:
Experimenia[Technology �SubsideoceConfro[ tt. ft:
Geothermal(i;losed Loop') OTracer 3t1 15ft3Gf tyt� nt'ii lt;nd't!t'<ai 5htefe3t:
Ft1OPi CU i)F5CRth1 TO1(color hardnem sonlroelt a aIu sire:etc
Cieothennul(Hutt#tt+C ting Retuni) other(ex lain wider 021 Remarks)
lo, R. 1,26 f i-
4.Date Well($)CtimplMed: Well)m ft. ft.
OMAJ
5 V tcllLocation' .., fr. rc. ! �`L`t
rotM1V1Owr*T NOmcl AFautl Iq (Irapplie bleb ft ft.:
Cu....... fl::
Ph, iwalddres C;fy;and Zip ft ft. �h�7
21.�.REiVT;3T2FGfi.. ;U
- WT CRunty :. Faecal ItiemU:ation No.tl'iNt
Sh.Latitude and to de in degree/minutestsecunds or decimal degr em Sg /+
(ir{rell frlil,ane"iatfloi{{t s sullicitntJ 22.Certification:
G,#s(arC}the tvell(s) ermanent ::or OtempHrary Si attire of ified Well Con:metor Date r l
- tie A{burg rlut et,n r r,+rrft rrj rJrar the scttfld nws(x4itr!en,tsiricrrd.n.,_cirrtOtier
7 IS flxsa repair t an exlstittt swell: QYes or +irh 15 t.tC tt,r1_t..t,trlt!<!, 1;;.1t'ilt Ua{".tj?tlrt Tfctt Coiacttu loon 5tuudnrtls ttnd thtu a
ltthis is,d:m'Jwir,,Tit ont dnotnr b ell t'uttstrtr"iu» frljurinatlun urrd eziplimr dw niitrtre.u;!lee ro#Ir r,(rhts 1'&Cord It-bev,jwar!drd ri the,nett o�rter.
a rlxur rorder 4.21 remarks oiru,tu�ret thn
23.Site dingram or additlonai well details:
g.T•or Geoprobell)PT or 4'tosed-Loup CcothermsI Welis'having the sonic You tttay use:the bach,tot:•thic page to Am ide atiditiottal-well:site detatl�<or 4+ell
construction,only t G -1 is:tiectlee;.:indicate Tt3T..41 Nt.lj�tk3E1t.Rt'ave,ls raiistnletiun deiail,. �'oa may aisc>aitach aiiu�iticv7al p iges if tiiressary.
untied SLBMVI fQ,L IVSNUC I(AS':
91761101 svelldepthbelosvlaudsurface (B-1 24a. for !l! �;etls: Submit thrs form within 30 days:of completion of welt
For tnultrpie swells leer rill rtrprhs ij d JTerrrtt mpte 34 w) a )
constntction to
the fall6Wii
11) Slattc:%vater levol below>lop of easiirg;-=--.C- :: (ft.l Di.isiou of Water Resources,Inflonnatiori.PCOCe5Sinli Utilt
�t xvrer lntti.i is llMJVS urstng,uli--' ... .::1617 iHAi1.Sei3ic.Cenfer,'Italetgh G,2?G99=1�G17
1t.Borehole dtamctcr: (ia:} 24b. For luicetion}3'ell In addition ra sending the form:to the address to 24a _
above,also stiiatnit one copy or th s farm iVitltin 30 hays of cottt(ilelaon of tvtii i2 4Ye11_constfvetlofa tm:thnid:T-- — ._ coastntction to the t0lluartnb
(1 t.au{wr;notary.eagle,dif&II piiih etc.{ `�
Division of Water Resources,'Underground Injection Control Program,
FOI2 WA TEl2 SUTPL WELLS C)NL)':
t63ti Mail
Service Center.Raleigh,.N 27S9"-.,JQb
I3a.S'ield(gent} l9ethott of test: 24c.& Watcr Sttppiv:& In{ecYlon�1te1}s to addit an to stadtng, the:fornl to
jj��t the acaltsa(es} aboie oleo outaiiiiG one ctflly of thig fnlsn within 3fl Gaya of
13b.Disi.. lion type:_ Amount: t 7 L compl,uon o;'well C-onsttuclioii to the cviiiity heaith.depatftoent of thc:counry.
where constnlcted. : .
iornt t;ti-l: North Carolina 1)4rartmrni of E ntirnnittt.ulat Qua -Diaitiirnt of Water Recuufee± ftevisesi?-22 1D16