GW1-2022-09167_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD(GW-1) For,internal Use Only:
I.Well Contractor Information: -
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1' VWAIMRUNES § + • „ S ,r. a 4 A .... "
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Wc1ICu'" orNatne FROhf TO I DESCRIPTION
NC Wetl Contractor Certification Number S� t
//// :15.O1flERCrt` SIN4"(forilti-ceiedlls flR�1NER. b
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J t 91"I/iI j FROM TO DIAME ER THICKNESS MATERIAi.
Co Name tt '' id,
ES
aY `76:INNER'CASING:OR"fi18 IN C° ttierrtuilel
2.Well Construction Permit.9: t?C�M`1107Z�1 FROM 7a DIAMETER1T7IpCNESs MATERIAL
Llrt all oppllea le x ell cpasnvetlon primtta(ue.u1c,County.State.mariante,etc.) R-
3.Weli Use(checkwell use): n. a- t"
Water Supply Well: 17.'SGREFd!f
FROM TO. I DIAMETER SLOTSIZE I TfnCHNM I a1ATERIAL
OAgricultuml i3municipamblic 25-fL y j ft. [n
OGeothermal(11catingAGooting Supply) 0Residential Water Supply(sing1e) H, it,
DIndastrial(Commercial OResidential Water Supply(s1tw-ed) + ,� -•
48 GROt71
Wgition . OWells>100,000 GPD FROM TO MATERIAL EMPLACEAIENTT OD R AA1DU
on. atef YWeilSuupp - - _ _
P
OMonitoring_ ORecovtry ft. ft.
Injection Well:
OAquifer Recharge OGroundiwnter RemWiatinn ft
OAquifer Storage and Recovery OSalinityBlier 1[9:;SANDiGRA G PAeFt' "i'°uI nrAL amPLAtaatFxT atarHOD
FROM To a1A7r
0AquiferTest OStormwaterDrainago R- ? r'o .r lCs�Gr"YC /C 9�twt`T
OF.itperimental Technology ❑Subsidence Control
OCieothermal{Closed Loop) OTrarer, c2WDRUXTNG JZU�LMG,attseh ddidd b"S'efd1rVicessi*)=�° r,
O(leotbermal fHenting/Cooling Return) OOther( lain under 1121 Remarks) FROM TO DESCRIPTION color,hardness,soiVretis a airy,ale
fL
()CoP fL ft fi
s di leted•". Well1TF0:' ft, -s ?
4.DateWell
SjhWcil Location: ft, tL F O 2022
n: ft
E '" Nome v Facility ON(ifappficabla) - _r. n,. ,-,
Gi
ia2U Sit 4umadle_ Alf.l fL ft
Physical Address.CiandZip tL fL
7f9 V� 27::REMARKS" .�.-
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutedseconds or decimal degrees:
(if well field,one lat11ong is sufficient) l
22. ficanon 10
6,is(are)the well(s): *rmanent or OTemporary Sti;MttirP� Cetlitied Weil Contract i to
By signing thirfornk I hereby eertio dW the NeU(s)war(acre)cow"ctedin accordance ratith
7.'1s this a repair to an existing well: Owes or 0 ISA XCAC 02C.been 0►00 or 15ANCAC 02C.0200 Well Construction Standards and fimt a copy
I/thir it o repair,jdl out bmrsn w+efl eonrtnacrtan!»fanmattoa espfaPn the nature of the of this record has Jr''O9fQed to the urll miner.
ri pair under*21 remarb seelion or on the bock of thisfiym
23.Site diagram or additional well details:
8.For Geoprobc/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional wen construction info
construction,only I GW-i is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled �-+ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below Land surface: " J O Submit this G W-1 within 36 days of well completion per the following:
For muldple wells list all depths tjd petent("arnple-3 00'and 2@100)
M Slade Prater level below top of casing: (fL) 24a For All Webs: Original form to Division of Water Resources (DWA),
If vk*level is above casing;rat`'+~ in formation'Processing`Unit,1617 MSG,Raleigh,NC 27699-1617
Il.Borehole diameter:' (] An.) 24b.Foi Injection Wells:Copy to DWR,Underground Injection Control(RJQ
Program,1636 MSC,Raleigh,NC 27699-L636
12.Well construction method: M L1ll re® n i''� 24G For Witter Su 1"And'O en-l.00"Geothermal Reiurn Welisi'Copy 18 the
(i.e�ager.rotary,cable iluect push etc.) oountyem,uvnmenta health department of the county wbete installed
FOR WATER SUPPLI'WELLS ONLY: 14d.For Water Wells'producing over 100 0001611 GPD:Copy to DWR,CCPCUA
n rt gram,1611 MSG,Raleigh tNC 276 9-
13a.Yield(gpm) Method of test r``t ( Perin ; ,
lab.Dlsinfeedon type:.9 7_// Amount: 0
Form GWA North Carolina Department of Enviramuental Quality-Division of Water Resources ! Revised 64-20I8