GW1-2023-02116_Well Construction - GW1_20230303

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WELL CONSTRUCTION RECORD(GWW 1) For Tntenlal Use Only: -
1.Well Contractor Information:
.,L �P� I t /�r� 14.�A�xlzoNrs
I, %11 Contractor Name FROX I TO i DESCROTION
4 �- —�`t /p o ft. t o M
�p 2.I gem
1• f7 ft- �6 I / it
NC�Yell Contractor Certification Number
� G�?✓
Do b j r j r t p(1 r I J 1510 CER CAiSING.for ritult-cased 1 s OR LIN);R tf A llcahle
bi [ on I!16��� FROM 1 TO ➢UMUER I TffiCKNESS MATERIAL
!i Company Name ft. ft in.
�rj �Q �� I6."MIL AS ING ORTUEING(eothermalclosed400 )
2.Well Construction Permit#: , e/ U �71dt
TO ➢L4bMTM TIRCHNEss 1kUTEFU,
List all applicable well construction perraus(i e•UIG Count;State,Variance,etc.) ft. in.
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3.Well Use(chesitwell use): fi.
Water Supply We'll: 17 SCREENI
4 I Agricultural traici allPublic FROM TO DIAMETER sIOTSIZC THICKNESS Ma_TER
P ft I ft in
Geothermal(Hcating(COoling Supply) esidcntial Water Supply(single)
ft I ft in.
• -Industrial/Commcrcial DResiderttial Water Supply(shared) 18:GROUT
Iriigatian FROM ITO MATERIAL EMPLACEIMUr METHOD&Ah7
Lean-Water Supply Well: ft I O ft.
Monitoring ORecovery rL ft.
i � Injection Well;( � Aquifer Re charge E3GroundwaterRemediation ii: I ft
19.SAND/GRAVEL PACK(tEa licable
fi—flAquifer Storage and Recovery E1Salinity Barrier FROM _I ITO MATERIAL I EtvtYLACE11rINT M1TETH0r
Aquifer Test OStomrwaterDrainage ft. I ft.
Experimental Technology OSubsidence Control ft. ft
jr Geothermal(Closed Loop) OTracer 20.DRILLINGLOG(attach additional sheets ifnecessarv)
Geothermal(Heating/Cooling Return) _ Other(explain under#l•21 Remarks) FROM ITo DESCRIPTIOM(color.hardness soi0mck tv a rainse.
ft.
Igo ir. Sfa
`! 4.I}ate Wells)Completed: 7` Well 11D# g� ft. 4 ft IrQ 141(LIP
5a.WellLocati/on: I Z ft I ft' dt!f/)
Eaciliwown Name Facility lD#(ifapplicable) ft I fi
Gr-et rn v'Pw Dr. t rsovl ft I
i l Physical Address,City,and Zip `�9 ff. I ft \ e (
`l3/ 1 V0OLL 21.RFMARKC' I L
County Parcel IdentificationNo.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(iEwclifield,pA lattloug is sufficient) i
®3 6 22.Certitieatio
Sq
6.Is(are)the well(s)MIFermanent or tOTemporary stgnamrc ofCettired Well • tractor Date
By signing this,brn,I hereby certify that the w0lls)wvas(were)constructed is acc
7.Is this a repair to an existing well: OYes or M&O wirtr 1SANCAC+02C.0200 or ISA NCAC 02C.0200 Well Constnrctron Standards or,
Ifthis is a repair,fdl out knovm Well construction information and explain the nature offhe copy ofthis reco rdhas been provided to the ivell'owner.
repair ronder-u21 remarks section or on the back ofthis farm.
23.Site diagram or additional well deta17s:
3.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same YOU may use the back of this page to.provide additional well site details
i! construction,only!OW-1 is needed. Indicate TOTALNUMBER of wells construction details. You may also attach additional pages ifnecessary,
dtilIed: S[I AIMAI INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a.For All iRrells: Submit this form within 30 days of completion
I Formultiple ivells list all depths Tdierent Ci rample-3 aQ 00-and 2Q100) construction to the following:
! 10.Static water level below top of casing `0
'If water level is above casing,use' `J ( ) Division ofWater Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 276994 617
11.13arehole diameter: (in.) 24b.For Inie I tion Wells: In addition to sending the form.to the address
I .12.Well construction method: 1 t , f tf� above also submit one copy of this font within 30 days of completion
(Le.auger rotary,cable.direct push,etc.) constructiontolthe following
FOR WATER SUPPLY WELLS ONLY:
Division oflWater Resources,Underground Injection Control Progr
i 636 Mail Service Center,Raleigh,NC 27699-7,636
13a.Yield m
I f$p ) � Method of rash: // i 24c.Tor Water Supply&Injection Wells: In addition to sending the:
the address(es) above, also submit one copy of this form withiii 30 t
13b.Disinfection type: HT H Amount: /) '�� completion of 16-11 construction to the county health department of the
�i where cnnstmeted.