GW1-2022-09955_Well Construction - GW1_20221104

WELL CbNSTRUCTION RECORD'(GW 1) For vltemal Use•Only: '
1.Well Contractor,Information: _
I a4:fWATERTANFB`:1:+7a(�wvnt:e:ff,:iZ rL,�? "t+U: '� t +• r:•vq:;;s.•y
�_ FROM 70 DESCRIPr MU
WeUCon4actorNeme ,
a
NC WeUCont1ctorCertificattoaNnmber. S�S;p11TERQASING WE ad ZIlVER a"'Utgble;�Kfi,x,j:A;z. i
fl it/f ���• y�� FROM TO . ' I Dltlhfts7•ER TffiCINNEss NATERML
t•LR• may • '�• .s' a v� „
CompaayName R16}II�IIVERCA$INGOBt17iBING eolher'a'fdlelmedrla`o'?•:a�.,,it,3,?r- :iil3ro.L a
2.Well Construction Permit#. • �,� �-. 9t FROM -I TO I WAMErER. TFBCMMS i MATERLIL
Litt all applicable tveUeanstmction pp=1q(L&WC.County.State,Abrianee,etej & 1°••
3.Well Use(checkwell use): it. R.. In.
WaterSuppbrWe11: :.z17:SGREIIH�:c SF�".•�'••:l�•"s�::fu.�ii3.:4:ri�t;'.R• •6:4':•i t'ti*:r�fs;>V�a•Fr..�i:w;'•�,,c::3,rii�' s .
A
FROM TO DIAI1W= SLOTSUSE . TMCMESS MATERM
icuI�j [3MunicipaMblic O L to. •
Geothermal(Headng1Cooling guppiy) Wesr1diuM Water Supply(single) a In.
lndustriall6ommercial. [3ResIdendalWater•Supply.(shmad)
�18.z igROI1Tf.�a}tirE„>.Z:iv�.•�:�,fa?,a�..a :i{is"fi�c•"•C`.'di''�et�u�}'Si�:�is'S1:�',���i+ti,nY.hia�.?:�
hti tIOR FROM TO MATERL&L EMFWCEIIffiH1MEMOD&AMOUNT
Non-Water upply Well: &
Monitoring 13Recovery fL ffi
Injection weM, ;
AquiferRecbarge ElGroundwaterRemediation
49 M4ANDIGRAVFMPAM- a"Uable r•'l;r•'.ASS
Aquifer Storage and Recovery. . E3SalkityIiwder .' FROM. To MATERIM eMFLnca►mNYMMOD
_AqutferTedIt� 13StormwaterDrainage fe
EverimeatalTechnology MSubsidenceControl ft. fL
I ' .
Geothermal(Closed Loop). ' [Tracer 12 DD.::.',:"v LOG affircI idditiSa`nlebeeti lfriee`eisa w`k:`•C;:s�. , ,rot •,�
FROM TO DESCRnrT10N eorerdaMn aetU�aerc e!
Geotherm ea6ng/CoolingRetum) Other( lainunder#21Renrarks) i
4.Date WeI<is)Completed: t5 2•Zi Weli mp ft. �"
$a.Well Location: ft: ft
e, r
411
FAoititylOWaerName _ FaaftINC.Eapplable) %_fL It
Z' t~' ���.,�ryi�.g l/ ,t h R LOAAA. W. At rt:
,
1Fbs+s1=IAdd's,Cfty. d* ft.
120 Ry,S� .,2:: 'oll ��4:,e�i"sIo'u}�vFy 9'�4'•.5y.4Ya4:a�i i":Y� -',s�nS �!
Uriz'
County 1 :ParcelIdentMoationNo.(PItU
5b.Latitud$and longitude is degreestminutedseconds or decimal degrees:
(ifwellfield, aelaNiongissuffident) 22.Certifieation: .
�•� ' .��� NA9.22' �1 .' , w
6.Is(ere)thewell(s) . Permanent or 137emporary Si a eo Cettib WeUCoaactor DaTe
By dpft fhtr jbrM I hereby eat&chat the 1vei1(s)funs(here)constructed In accordance
7.bthha4palrtonnexist1ugwell: E3Yes ort�i1oo lvithISAMICOW.0I00or15AWAC01CA200WeUCoatradlenStarulm*andthata
ifthisfsa repairJIU out hnotvntvauconstruada'a. fommtion and erptatn the nature efthe copJ'ofg*recotd)iafbeenpmvfdedtothamUomer.
repafr under 02Z remark section at an the backofthfsfomr.
23.Site diagram or additional well details:
8.For GeoprobdDPT or Closed=Loop Geothermal Wells having the same You may use the baoY of this page to provide additional'well site details or well
construction,only 1 GW-1 is needed.ladicate TOTALNE"ofwells construction details.You may also attach additional pages Nnect=W-
drr'llai: I. SUSMITTALINSTRUCTTONS
9.Total well depth below land surface: (ft) 24a.For Ail Weila: Submit•this forth withfn'30 days,of completion of well
Fortmridptaxellsllrratldepthr{jdl,Birant(armipl�3(d�ZOO•andlQlOD� constructiontothefollowing:
10.Static ytater level below top of casing:. (tt:) D"lon of Watek Resources,Information Processing Unit,
Jfvarerfcvdfsafiavecasing,the'�1 1617Mai1ServiceCMtCr;Raief?,,NC27W-1¢l7
11.11orehole diameter: (in.) 24b.For Intecdon Wells: Ia addition to sending the form to the address,M-24a
I above,also submit one copy of this form within 30 days of completfoa of well
12.Well eo truc T 6on method: /D ,4 r 1/ construction to the following.
(ie.auger.r+M cabte,.dhdpusb,etc.) '
Division of WaterResources,Underground Injection ConteolProgrnm,
FOR WATER SUPPLY WELLS ONLY: ._ ( 1636 MailSeMce Center,Ratelgh,NC 27699=1636
13a.Yield I Ipm) Method of test: r 24c.For Water Supply&Iniectionl Wells: Ta addition to sending the form to
� the.address(es) abovq also pbmit onercopy'of'this tome widiin'30 days of
13b.Disinfectfontype:�I/�iB�,,n"ei Amount: '. 2 C7 Z completion of'well construction to the county health:department of the ecmtty
i where constmcted.
Fnnn[:W�1 I un.rfi ttian,linw nenaefinenl nfRnvrmnmenMltlualtM.1]rvktmr'nfWa°MR.cnun.,.��, 4...te..1911971Nt •