GW1-2023-02129_Well Construction - GW1_20230303

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(' I.Well Contractor Information:
PAIL za.Wttzorl�s
Well ConuactorName IItOR£ If0 I . DESCREMON
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NCNVcUContractnrCccationNmnber 2,25'ILjL27 �+
15 ODTEItCASING for edwe s O LINER tf ]icahIe
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CompaayName i 1-1 ft: � : � G ia. SD2^?l PW
^^��0-386 16.I RC1iS1I�Ia ORTQSlNG f eathermaldnsed zoo 1
1 2.Well Conslructiorf Permit#:J b C! PROM a D TEMM EssLT
FTERUL
Listallapplrcable tretl construtivn petmtts O-A UIC Coundl;Stag Patfmace.elm)
3.V{3e11 Use(cheekwe[1 lase): ft: I � #t, im
WaterSnpply Well-. 17.SCREEN -
PA cultural — FROM TQ ! DTAML+TER SLOTSiZE MClowsS MATER
gn "crpal/Ptrbiic � I � Ln.
Geothermal(Heating/Cooling Supply) R�sfdendi -Vfater Supply(single) f fr~- in.
radustrial/Calntnecciat � esidential Water Supply(��d) Ig,GROUT I .
Fmgatlan xltotvi ITD' nrarrdr EMPLACEMEtITb�i$OA&A14t
Iwou-water Supply Well: & .
ay POW
MonitoringReCQVery It ft.
Nection Well:
A under Recharge ft I ft
9 g �GroundataterRemediation
Aquifer Storage andRecovery OSalinityBarfler 39 SANDIGRAVELPAL'ff(tta 'ticable
RROM - I I 7+IATER>AL EMQLACEI%MTM-TRoI
I; AquiderTest OStormwaWDrainage fill . ff-
Experimental Technology ]Subsidence Control ft I ft
` Geothermal(t"losedLoop) QlTzacer 20.1)R�GIOG7affn hnddiionalsheetsifnecessa
_Geothermal(HeatinglCooliggRehrm) - Other(explainunder 2lRemarks) To' BFSCg K[eator.barana9 snatrorr ty e4cnrns;z�
6 ft 79 it. PEP-
4.Date Wetl(s)Completed: I" WellllD# W tt. }LrZ fr. fgni7�'2
5a.WeIlLacat! `Z7, ft earn ft [ �1,
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,I E¢cili /OwncrNamc ft I fi: t•-. - ; TVr'j^ 1
tY Facilitplp;f(ifap 6cahle) 4.s,
f�5��gn� f�(Vpe fIn0olnemvile, lU� iz���s
Physical Address,City,and Zip tt I ' ft
MAR
- County Parcel Idenriiication1Qo.(PIN)
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5b.Latitude and longitude in degreeslminates/seconds or decimal degrees:
{iftivclLfield, att[angissufficient)
22.Certitieatid
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6.Is(are)thewen(s) rmanent or •EITemporary SigaatmeofCetL$edWell r Date
I'I By srgnFng this f6alit,I hereby certify abut Ore well(r)ivar(were)co=rrucred in or
7.ls-this a repair to an existing well: Dyes or. No elate IS_4.0AC t12C_0100 or JSANCiC 02C_020D Krell Constnrclion Standards air.
Ifthis is a repair,ftll out Iatatsn tvPll construeliortitrformnfiotrand vapplain rlre trar,+ro oOh-* spyafrhisrecari hasbeettpravlded to The melt oiMer_
repair under 01 remarks section or on fire backofiWora.j 23.Site diagram ram or additional well details:
•I S.For Gaoprobe/DPT or Closed-hoop Geothermal Wells having the same You may use rhe!back of this page to provide additional well site details
construction,only 1GW-1isneeded_ Indicate TOTALNU BERofwel(s constmetiondetails.You may also attach additional pages ifnecessary
drilled: SUBM "AL INSTRUCTIONS
9-Total well depth below landsurface: 4 L,' (M) 24a.For AII Wells; Submit this form within 30 days of completion
Formadirple%vrlls&t alI depths sfdifferaut(-znnple-3@200'and 2@IOD3 COnSIIaCtion t0 the following:
j 10.Sfati vel is a r level i g Its top o€casing; V (ft) Dlnston o€Water Resources Ittformatinn Processing Uni`
i 'Ifstater level is above casing,arse"'••" � �` b
1 517ATAil Service Center,Raleigh,NC 276994617
I1.Borehole diameter.
j 24b.For In'ee'nn Wells: Jn addition to sending the form.to the address
12_WeIlcaDsirad ton method:�t r 1\d lq�(/ above,also sub ` one copy of this#onn within 30 days of completicIL
` (Le.auger,mtaty,cable,due ctpasl�,ete) F constractionio 6followina
i FOR WATER SUPPLY WELTS OPILY DilisionofWater Resources,UndergroundNection control Progr
y 1636 ilaM Service Center,Raleigh,NC 27699 636
132.Yield(gpm) 5 Method of test:
24c.For Water Sunnly 8e rniection Wells: In addition to sending the:
oZ the address(es) above, also submit one copy of this form within 30 c
13b.Disinfection type: Amount: (� cdunpletion of v�reeSl construction to the county health department of,the
where coast me
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