HomeMy WebLinkAboutGW1-2023-02128_Well Construction - GW1_20230303 '�I I
-WELL CONSTRUCTION RECORD(O� 1� � I -
Forlrtttem i Use only:
I.Well Contractor Information:
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Well ContractorName MOM r DESCRn'1ION
NC Well Contractor Certification Number `ZV IL ft
J 1S OEITEItCASSNG farmat&�sedwetis OR7NER m licabIa
�� I j r f j BSI bT TQ DLl11fETER T$iC[{NPSS MATERIAL
Company Name fE: i in.
16. stC G ORTE7SING. thermaldosed-Ioo ) !_
2.Well Construction permit#:-.)CI G2Z �xoxt Tp nrs,Mt i�E TmexNEss 9IATERL4L
Ust all applicable will constractionpetmfts(l a Eft,Count};Strag Yntiance etc.) I ft. in,
3.W811 Use(Che&wefl Rse): ft.
Wafer-Suupiy Well: 17.SCREEN I i
Agricultural FROM TO SpTSJZ s MATER
tetpal/Public ft. I ft. in
Geothermal(Heating/Cooling Supply) Rcsidential-W2ter Supply(single)
fE. I it in.
Industrial/Commercial OResidential Water Supply(shared)fi
itl.GROIIT I
IlL-Wat n FROM TQ rtreTt uric IENPLACFN�NT fYI HOD&AM
l�ton-�WaterSugply Well: iG
-MonitoeMg Recov ft
kiection Well: '
LAquifer
er Recflaz e I ft
S E3CaoundwaterRemediation
er Storage and Recovery (Salmi BarierF! TO MATEMAL EMPLACL•it mrmETROE
Test E3&DmtvaterDrainage ftitmental Tecbnology Oftbsideuce Control it I ftermal(Closed Loop) OTzacer 20.MU19NGLOG fattish additional sheets r-tneceermal(Pleating/CoolmgRetum} 0ther(explainunderk2lRemarks FROM � nESCatt�T[oN[cotor.bacaoess snarrocht �rtn5
it: i Z. it.
d � �i-� Sad
4.Date WeIl s Co leted:q'-Z2_2� 1115 1c� firm}
() mP Welllgl# 7� ft ( it
Sa.WeRLocation: ft.
S'05CAn 13 Mlcr
Facility/OwnerNamc /n� -- f - r 7F^acilitgIIJ#(ifappGca6fe} I ft
1 "lr l i�S Lf' �1`C3T tJ 50.2fiq�P ft I ft
Physical Addtcss,City,and Zip ii: I it
e- — 13 jqq 13G-01a r.xl;,r�ttxs
it County . Parcel IdentificalomNo.(PIN}
5b.Latitude andlongitude in degrees/minutes/seconds or decimal degrees:
I [ifwc116c[d,��fRangissullicie>rt) -
Z2.Certifieaff
3c.3 7-1 813353 _
9--22-2Z
6.Is(are)thewetl(s)ePermauent or OTemporary SiEnaoneofCerefied.Wel[Gd t- ctor Date
By slgnPng this fo�,!hereby certfy!fiat tie iirII(r ivar 6vare)constricted in ace
7.Is this arepair to an mistingivell; E2-1--es or ON with ISANCAC82C-0100 or ISANC,(C 01C-0100 WPJI Corzrtniction Standards w.
IJ'this tsa reaatr,j3ft out larawn well consttuelionlnformtufonand explain the nanhre ofMe copy oftlhisrerar$hasbePtrprovidedto t(renelf mvner
repairvnderf21 remarks section or on the back ofthisform.
23.Site diagra I or additional well details:
S.For Ge oprob e/D11--i or Closets-Loop Geothermal Wells having the same YOU may use the back of this page to provide additional well site details
construction.only I CWr--1 is needed. Indicate TOTAL NUMSP.R ofwells construction detains.You may also attach additional pages ifnecessary. -
drilled: -o SiFSMITTAL INSTP.UCTFOPIS
j 9-Total well depth below land surface. ( ) I
24a.For All Wells: Submit this foam within 30 days of completion.
For m altipleivellshstalldepthsifdfferew(ecarnple-3@200'and2Q1 00) COnStiuctiontot(3efO110WIng y p
i
10.Staticwater level below tog of casing;
'!tarter level is above casing use-_^ (0 ( Divisaan ofl Pifer Resources,Information Processing Unit,
,I 7 Mail Service Center,Raleigh,NC 27699-1617
i 11.Borehole diameter. (�
! /n� R 2fib.For Inlet Pion Wells: In addition to sending the fotm.to the address
12.WeIlconsfraeflon method:l7 1 !{GG�ti �0v� oue copy of this form within 30 days of completion
s.e.av construction to tltd foIIowinp
' f Re,rotary,cab!,daectpash,etc.} -
I Division ofl'ater Resources,Underground ection Control Pro r
FOR WATER SUPPLY WELLS OPILY: 1636IV3ail Service Center,Raleigh,NC 276991,636 g
13a.Meld(gpm)5r Method of test:Af r {-►Fr 24a For Wate I SIMIDIV&In'ection Wells: In addition to sending the:
i
the address(es) afiovc, also submit one copy of Plus form Zvitltin ail c
! 13b.Ilisinfeetian type: Amonnt: Oz completion of veil construction to the county health department of the
Where conshacte