GW1-2022-06833_Well Construction - GW1_20220715

+' 1 IItit,1 Vliil
WELL CONSTRUCTION RECORD(GW 1) For Intemal Use Only: `
1.Well Contractor IMor Arlon:
(g'� 5 14.'W TER ZfiNES
Well Contra acne FROM I TO DESCRIPTION
ft. .
g566 A ft.tt. ttG 4r �
NC Well Cotisactor C don Number 15.OUTER CASING Her imu1N w0 f)R LIN 13t
61lra g `. FROM I TO DIAMETER IMCKNES5 MATERIAL
ft. ft. I.tn. p '
Companybime V
C"1 6 c I 1 —1 Lb 2 b 16.Malt.ca$IIVG oR TUMNTG a i thermal close
"awl
Well Construction Permit#: i 1 ` FROM To nrAUL=' i I 7711COWSS A MATERM
.Gist all applicalik-weil constructionpermlis(i.e.WC,Como-.State,Variance,etc.)
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER !sun SIZE TWCttNESS MATERIAL
Agriculuuai unicipaMblic ft. ft, in. i'
Geothermal(Reatulg/Cooling Supply) Residential Water Supply(single)
Industrial/Cominereiai 011csidential Water Supply(shared) IL
ItGRO'[iT.
NaFROM TO MATERIAL EMPLACEa METHOD AMOUNT
Non-Wter Supply Well: a ft. �® ft, h V-
r
M�itorhug Recovery
jection Well:
Aquifer Recharge E30roundwaterRemediatio IL ft.
n
Aquifer Storage and Recovery yyog i Barrier 19.SANb/ M PACK f . licable
i.,? tY FROM TO MATE Tm," EMPLACEMENT METHOD
Aquifer Test [IStormwater Drainage ft. D•
Experimental Technology Subsidence Control ft• h• i i 44
Geothermal(Closed Loop) DTtacer ?A.DRILLING 1,OG attach addidonol alieets tf n
Geothermal eatin Coo' Beltran) Other ex lainunder#21 Retularks FROM TO DESCRIMUN'colorha i roek e. lesu ere
d let V II
4.Date Well(c)Completed: 5 —J o^21 Well M# Q ft' 0 fL C1 k, L�
5a.Well Location: R' Z0 ft. 1,a h'/t o L
Facility/OwwNatne Facility LD#(if applicable) ft. & ram.. 'd
tn la,
a
PhysicalAddissa,CiM and Zip f D J a� f s f 15 2022
V)����,,, 21.
Coo* Parcel Identification No.(PDO
5b.Latitude and longitude in degrees/miuntea/seconds or decimal degrees: " 1F'PC! ' A pr'U
(ifwell field,one lat/long is sufficient) 22.Certification: !!
6.Is(hre)the well(s)dPermaneut or OTemporary Signature oPCcrtlficd Well Contractor I t Date
By siguing this form,I hereby cer fify that the urA(s)was(were)constructed to awordmice
7.Is this a repair to an existing well: dYes or ONO with 15A NCAC 03C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out knoun well constructim information and explain the nature ofthe cap)'ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis form.
23.Site diagram or additional well details:
8.For GeoprobaMPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW 1 is needed Indicate TOTAL NUMBER of wells construetion-details. You may also attach h iadditional pages if necessary.
drilled...
SUBIVIII'TAI.INSTRUCTIONS �!
9.Total well depth below land surface: (fk) r
For multiple wells list all depths#'d+i erent(example-3Q200'avid 2@100) 24a.For Ali Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: 2 (fk) Division of Water Resourceo,Information Processing Unit,
If water level is above coshrg,use"+" 1617 Mail Service Center,Raleigh,NC 7699-1617
11.Borehole diameter: (in.) 24L For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:. d I r r&q r_' construction to the following:
(Lt.auger,rotary,cable,dkerAposh,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,� ,IRateigh,NC 37699-1636
13a.Yield(gpm) MAW of teat: �� 24c.For Water Smmty&lniect(�a a W 1 .1 k addition to sending the form to
the address(es)*above, also submit one!copy of this'form within 30 days of
13b.Disinfection type: Amount: I completion of well construction to.the county health department of the county
where constructed.
FormGW+1 NmthCgmlinaripmihnentnfRnvinmm�w..fnfn..eu; _nt..i........rur—n-......... I