GW1-2023-01757_Well Construction - GW1_20230223

I
WELL CONSTRUCTION RECORD(GW-11 For Tnternat Use Daly:
1.Well Controetor Information:
larY1 A S �„ 1,L WATERZONE9
)VellContractorName 1R011 TO DESldtnOIN
NclVellCcwtmaorCedificationNumber i&tal7 IM CAA 3ING(lbrmottl•casedttm3is OYtLIIVERtIf )
S2�U i CAS Vic Cott 'ro nlitRt rmemss I nti.Tl;itrar.
ft it. in.
Cmnpany Nama i.
1b.lNNIIL CASIlVG OBTIlBING(n.nt,.�,eE closed—loop)
2.WAH Coffitruetlon Pemlitff:, a— 61�� r'1031 m n1A11lElBR Mt:KKW bUTERIAL
List all applicabie trek constriction permits((e.UIC.Camay.State,variance,Mc.I (� R' S3 O• (� , Z,T�°' $•�n 2\ V C
3.Well Use(check well rise): lt. ft. ;
Water Snpp1Y Well: 1T.scsirl
�1VIanr
FROX TO DfAatt31!R SLOTSiZE TSICr:14PSS A14LERTAr
Agriculntrai ' blic R. ft. 3u. •
Geothermal(ficating(Cooling Supply) bitdidential Water Supply(single) R, ft. in.
IndustriaUCominercint idemial WaterSupply(shansd) I&GROAT
iiz{ 7tit1R FR01i TO hiATERIAI. 13fiLACE\11a\7 hfEfiiOD&ANlQb—NT-
IVon•Water Supply Well: -O rt. 10 h• tie h t PO'�1
Monitoring Recovery g,
rAquiferTest
iou Well: `
R: R,
tferRecharge E3GmundwaterRcmcdiation 171.SAND7fiSAVEi. Ate 1Frable
iferStorago and Recovery SalinitySaxricr FROM TO aMTERrw EttmLAMIEUrttEMOD
[3StarmwaterDrainage ft, Merimental Technology DSubsideace Control ft. IL
therroal(CloscdLoop) E3Trdccr 20.DR]LIMIGLOGtr+ttaehoddttianeltherind(Hcatin lCoolin Return) Qther(e atnunder#21Remarks) O To nxsL�le2lol�tmtm,a�anKr,�tueuk e, ,�ze�ri
r-3 ft. ON OYer,6Ur-Ct,L+\
4.Date Well(s)Completed: 1; 1 i• .3 WellW# trS'3 R• os�' rA h
ga.Well Location: rr ,'' $• R•
racnityldwnerNamo Facility IM(if appncable) ft: fG - yu
Physical Addrew.City,andZipUnis
R.
-lAf 'law
v41+Q �t=
County Parcel rdentificecion No.{P�9
Sb.Latitude and longitude in degrees/minuteslseconds or decimal degrees:
(1twell held,one tatllang Is sufficient)
=C lon:er lift
3ro jqS t'.1 1 . `at,10i►tx.8l0s7 2 q
' . &Zn ?q � w .,
6Js(lre)the well(s)Qermanent or MiTemporary Sl gnamriro€CeltmaiWCUCoatractor Daie
� ey signing this form,I herelly certify that die nell(s)teas(were)conorurred in accordance
Al.Is this a repair to an wdsting well: Dyes or "� %&*h ISA NCAC 02C.0100 or ISANCAC 02C.0200 Well Constrildian Standards and than a
OhLv Is a repair:fill Dill knolm well conometion infor natron and explain rite nature ofthe copy afdtir record has been pm hided to the/wen atener,
repair under021 remarlmseetion oronthe back-ofibisforni. ,Site diagram oradditionctt wt11 detalLs:
8_tilt b'eaprobe/DPT or Closcd�cop Ccotltrzrtnal Wells 8nving the aausc You may Use the back of this page to provide additiorud well stto derails or wcil
construction,only I OW-1 is uvWud. Indicate TOTALIr'EnMSXR or-,vens etntstiaction dctann.You may also attach additional pagos afaeeessary,
drilled: // SI3QMiTTeE EtN¢raitOq
9.Total well depth below land surface: (D O� ( ) g�For All Welist Sub; this form within 30 days of completion of well
Formatdple tcelts list nit depda if&fertm(emmple-3t�09'and2@111D) 24a. uctioa to the felloSub;
10.Static-water level below top of casing: - O ift.) Division of Water Remurcess Information Prot Unit
If iraler level is abore casing,the"+" 1617 Malt 8"ce Center,Raleigh,NC 27699 617
11.13orehole diluneter:_ &I _ (in.) 24b.For Injection Welts:'In;addition to sending dle form to the addmss in 24a
12.Well construction method: 1 \o TL 0.r4 above,also submit One copy of this form within 30 days of completion of well
(ie.auger.rolmy,cabic,dtr=pus),Cirj��� - "� """ CQDSIIDCIIODIOIhefQA0N1D�:
TOR WATER SUPPLY'VM91S ONLY: 1llvisitmof Water Reumcl,�es,Underground Injection Control Program,
Iti36 Mail Sei*e Center,Rale%h,NC 27®91636
Method of tests"' Wnfbv;QM Ur-Far Woter Sml 1p v&,Ip f INA tt We tc' In addition to sending the farm to
C �t)� ,^ I -� I ^ the adtimss(es) above,also lubmit one copy of this farm within 30 days of
13b.Disin€ection type: Amount•" tie 4ek-6( Completion of well coashil'ctian to die county health department of the county
where comtmetcd. ;