GW1-2022-01190_Well Construction - GW1_20220121

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VFLL CONSTRUCTION RECORD ME-1) For intp{nat Use Only:
i.WellContractor Information:
14.'WATERZDNES',i. .;,:': ....,_ .. :.:_.
�lellCo arNe FROM TO DSSCR>TIION
IL ft.
& ft 8.�_
�C.Well Cor.*racmrCectiffca3onN[m3er 15.OITTERCASING'tformuitiwset<weus OBLIla>E[L 7icable -
`� ( .�i ..� FROM TO D7AFfETti[t TffiCI�iTFSS. MA7ER7AL
- s l e e. D i IL � � m. M
Camgrsay Name
16.INNER'l_'ASiNGORTUBINGfewlbermal.rScsedauo '
2. +ell Constrnc#iouPermit=': FROM To WI-AACT R ITn[cHomss MAisRltnL
l ist all applicable irzll construeiton permits r e UIC,Comfy Stag Yarianeq etc) S. ft.
3.Well Use(cbeckweD use): m.
iZSCREEN.. .: ...: ::.......
Water Supply Well: FROM To I DIANN= SWr= I T CKNESS MATERIAL
A_ericultural 13MutncipaUPublic ft. a. is
Geothermal(Heating/Cooling Supply) rlResidential Water Supply(smile) ft fL
Indus-uial/Com ner+cial AResidenual.Water Supply(shared) Is.GROUT
Irrigation FROM TO MATERIAL Et+irr A METHOD&AMOUNT
Non-Water Supply Well: ft jo
i
Monitoring ft. 0
Nection Well: & 8:
BAquif-Recharge C]Groundwaterliemediation
19.SAND/GRA'VLL PACfiGritapplibabljo
Aquifer Storage and Recovery 13SalinityBarrier FROM TO MATERIAL ' + SWMGD
L
Test OStonnwaterDrainage fa &
ental Technology Subsidence Control � m
mal(Closed Loop) Tracer 20.DRUXMGLOG atmeh additional sheets Namal(FIeatiag/CoolingRetum) Other(explain.under#21 Remadm) FROM To D Oiv(color,rardaes saatroek a nshx ere)
b fL @ h fL
4.Date Well(s)Completed: 4 � g"' Weil..#aa-1_�J* ft e d ft �o5 l
Sa.WellLoc2doon: t - L ft .e io f
ft
L &111/i `t 7a P.tr li�Yl,l
Fwflity/Qwc_arName Facili IDS(if W11cable) ft D
Physic-a!_ ' ft: ft.,and zip p C
zI.RENEARKS •
�j
County � ParcelIdenufrcatoallo.(P7I�
=b.Latitude and longitude in degreesiminutesiseconds or decimal degrees:
gweli geld,cue Wfilonn is sufficient) 2 .Certifirdtiow. ` (y
6.Is(are)the weli(s) Permanent or Temporary Si tare of Certified Well Contractor Date
q+ signing this fan nn I hereby certify that the well(s)was(were)constructed in accordance
T_Is this a repair m as existing well: Yes or No 15A.NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and Mat a
ytbir is a reD.::S, Gam:c.�aS4:.i4?'iCGlStlaCttan infOratalian explain the nature afth PS ofrhis record has been provided to the hell owner,
repauun.er lr<=rasa a aresvebautofthisform 23.Site diagram oradditionalwelldetallls:
&For t;eagrobefDPT or Qased-Leap Geothermal Walls having the same You may use the back of this page to provide additional well site details or well
willed.on,only I GW-1 is nccdc& Edicate TOTAL NUMBER of wells construction details.You may also atxach additional pages ifnecessary
drilled: 1 I SUBMITTAL INSTRUCTIONS
u
9.Total well depth below land surface: 1:'q A) 24a, For All Wells: Submit this form within 30 days of completion of well
For mtdhple walls List all d¢atFs ifdisftmt rimmnple-3@200-and 2(a}1009 construction to the following:
10.Static water level below top of casing: Cori (ft) Division of Water Resources,Information Processing Unit,
Ifwaterlevel isabarecasiag use`-" 1627 Mail Service Center,Raleigh,NC 27699 1617
11.BorehoIe diameter. d (m.) 24b.For Liiection Wells: In addition to sending the fora to the address in 24a
a above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: i hz R n construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Progrurati,
FOR WATER SUPPLY WELTS ONLY: 1636 Mail,Service Center,Raieigh,NC 276991636
13a.Yield(gpm) C Method of test:�' 1 240.For Water Sul'"' &Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: r Amount C completion of well construction to the county health department of the county
where constructed.