GW1-2022-09994_Well Construction - GW1_20221104

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WErs-, NSTRUCTION RECORD(GW-1) For internal Use only:
1.Wen Contractor Information,:�yr
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FROM TO D
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NC Well ConhaetprOtltiHntio¢Number ilWOUIER:CASING faun ti` iidwei�OR'LRVER
FROM TO DW,1ErER - TRICIQiFSS I MATERIAL
fr7 "6.,411 r 5 •grit t tfyz it' L fL G i_• 21 %'h'C-
CompanyName - Eli1NNER'• GOR.TUBING:cod canal olmedliio 'L^.'�T?,'ifi:'u'tradil.,ae.o
FROM - TO DM%7ER_ THICKNESS bfATF1OAL
2.wellCon6truefion]Permit#: � •� � / � fL ft. 10.
Lrstalf appOw (e,velf eanrbuedon penn7tr(Le.WC County.State.Parlance,ate)
fL tL iu.
3.Well Use(check well use): .�ss;°otasns
SCREF:N�:A`r'.S'L..•3:11;w�.i::L.?iv:P:7=!I;!r'.iarl."c
FA
upply Well: FROM TO DIMtETER SLOTSIZE TraIMESS MATERIAL
ultural Ohlonicipalftblic 0 ft. fL
ermal(Heating/Cooling Supply) [Residential Water Supply(single) R ft is
e7atiwConrmemial DResidentlal Water Supply(shared) 418:iGROM TOtion a R Fater Supply Well:torin Recovery rt mon ell: fL ft.
fer Recharge E)GrouadwaterRemediationPAQCifer Storage and Recovery Salinity Barrier FaoM To . MATERFAL EMeucTamrc lurrnoniiar'�estOStarmwaterDrainageerimentatTechnology oSubsidenceControlthermd(Closed Loop) LtTrdCer FROM TO DESCItiPl10N�obe:audvex.roiV,oethermal(Heatin Conlingit turn Other(arplamunder#21 Remarks Q Q.
4.Date Wells)Completed: r - 6
U R ft
Sa.Well 11location. p .. R R ` r:
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FhaOiglOwner a v� Facility M#(ifapp�ble)
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Couaw Pelldeati6eador,. .II4.
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(ifwell Held,one latllo¢g is suufficieno s / 22.Certification:
1412 J '7
1 `
`` Si eofCesH ed <lt Cantreetar Date
6.Is(are)thewen(a)(gPEirru ent or Temporary -by signing thrs form I hereby eert(ry that the+velf(s)was(were)camaueted A accordance
7.Is this a repair to an existing well: F]Yes or ®Nt6' Wth 15A NCAC 02C.0I00 or 15f NCAC:02C.0200 Wei1Comrmnfon Standards andthata
IJtbh@a rfttpa4,AH outbwn we aHeanraueHan Worneadon and ghahn the nature ofthe roPl'oJOvm°ni been provldedfo 4ie teerfmrner.
repatrunder#21 wwrksuctron or an the backofthisform 23.Site diagram or addition?],well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Well$having thesame You may use the back of this page to provide additional well site details or well
construction,only!GW-1 is needed. IndicateTOTALNUMBERofwolls
construction details. You may abo attacfi additional pages if accessary.
dnlied:� SUBMITTAL INSTRUC119N$
9.Total well depth below land surface: 0 (ft.) 24a.For All Wells- Submit this form Within 30 days of completion of well
FortnulOp(ewelfs lhtall depths ffd rent(aamplo-2 00•and2Q100) "asomcdonto the following:
10.Static water level below top of casing: �„C (ft) Division ofWatei Resoucninformation Processing Unit,
IJsratafnel k above taring me'+- 1617 Mail Service CenterrRalelgh,NC27699 7617
11.Borehole diameter. (in) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Il1i above,also submit one copy of this form within 30 days of completion of well
12.Weil construction method: t` 0 7Y construction to the following:
auga,mdsy.nabla,dheetpusb,ate) .
Division of Water Resources,Underground Injection ControlYrognm,
FOR WATER SUPPLY WELLS ONLY- 1 1636 Mail Service Centery Raleigh,NC 276994636
13a.$eld(gpm) /S~ Method of tesC r� ✓'I( T 24c.For Water S only&Infection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days or
13b.17 tnfeedon type: C/1 JC J" h'ei Amount: T U z!_ completion of well concoction to the county health depacoaent of the county
wbereconstructed.