GW1-2023-02450_Well Construction - GW1_20230404

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WELL CONSTRUCTION RECORD(GW-I For Internal Use Only:
1.Well Contractor Information:
K111' l(OS V►"1 id.WATER ZONES
Well Centractorh`ama FROM TO I DESOUPTTOY
ft, ft' 1
1769 3— (�I l q
f. tt ry
NC WVetl Contractor Certification Number .
. \ I II-OUTER CASINGKormnttl•cased wells)O$LINNElk or: . y: -j
TI Li ceevt I I ( PROM ft. TO DFA69Et THICSNESs< MATERIAL
ftCompany Name I in.
16.INNfiR CASING ORTiIBING(geothermal elaseddooM
2.Well Conan uclion Permit if:(55— a0 0 a-- GYM(0 b .FROM , TO 1 DIAMETER 4 THICKNESS MATERIAL
Lin all applicable well consiructian permits(i.e.FDIC.Comfy.Mate,Variance.etc.) 0 R• 021 It. Zr in Sb i2 2 1 PVC
3.Well Use(eiteck well use): ft. iu. t
Water Supply Well: 17.tiCREEi1 I I 1
Agricultural FROM TO ft, DIMIS ER SLOTS= 1 TSICkaiESS MATF_RIAi OIvlu "tpmYPuhlir ft. in.
ii,Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft_ in_
*iIndustrial/Commerclet DIftesidential Water Supply(shared) w
ilallri glen FROM TO- hfATERIaiL EMFLACEmFAT METHOD&MIMI'
Nan•Wa&er&lim ;Well: (3 ft. a 6 ft. (i f t y l W eou12
�i Monitoring ecovcry On _
Indention Welle f}. ft.
ati•. ifer Recharge EtGroundwaterRemediation ft. S.
111•quifer Storage and Recovery 0Salinley Barrier I4 SAND)GSAVELPA k: ttfagpl�aBlr}
6Roar TO 3Ih1E8L1E ElIPLACE1IE.krMETHOD
it'quifer Test DSturmwaterDrainage it. ft.
*Experimental Technology ()Subsidence Control ft. ft.
It Geothermal(Closed Loop) OTracer 20 DRILIINGLOGisitechadditionalsteels trnesessary) -
•
*Geothermal(Heatin./Conlin Return) it Other(e ,lain under#2iReatarks) 4I it
Oa • a I ev of_pEsCxttrrto�tt�tm;traiansaurtv:ltie.aretns;u.�ct
Ok,cr-j t o rcto 1'1
4.1)ate Wehl(s)Completed: 3-a 3-0 3 Well IMP rQ 1 a' 1005 G•1 ar0.i1,1•-2
Se.Well Location: ft. ft.
Jess Sl.evhere7s1 pobirI- SoLt.l2 ft. cc
SuctlitylOwueeName FaeluityID (if applicable) ft- fr. 1--- i; n�s.-a �:` fiT ss.3
_ �.. I
alto I=orcj Cire..a� nv Mt1IS River a81t S ll. . _
Physical Address,City,and -
t4rEp
r t it ft. APR` +� 2a�s
.t- rtf) arson Gioaco I (o3v-1S— 21.E .., . 7.r::1 Urn:
County Parcel identification No.(PIA ry`d a
5b.Latitude and longitude in degreeslminutestseconds or deeimnl degrees:
(Jr well field,one tatilong is sufficient) ?Z Certification:
,35° act 42•-50932-6 aN jf2" 31 ' i0. oleli003" W - . 2.
3-23 - 23
6.s(are)the well(s) ermr}nent or �ITemparary Sigirature o€Csnificd Well Contractor Date
By signing lair farm,I hereby certijp that the tiell(s)was(were)coilvmeted in accordance
7.Is this a repair to as coasting well: CiYes or o with I5A NCAC a2C Mali or 15ANCA 02C.0200 IVeil Construction Standards and that a
Irthis it a repair..fitt out known well cans:ruetian infasmutton andecptaiu the nature.of the COpy aftltfsreenrd has been provided to the treJl owner.
repair under 021 remarks section oranthe frackofthisform.
W.Site diagram or additional well details:
it_Par Co/spraho/OPT or Closed.Laop Geothermal Wells having the ulnae Your may use the cinch of this page to provide additional well alto clowns or wall
comsttmctlon.only 1 CY1-1 is needed.Indie=TOTALNuriIm of wens
construction deans.You may also attnchadditrotfal pages rFaeecsaary.
drilled:
SUBMITTAL iff%IBTRUCTIO
9.Total well depth below land surface: I DOS 014 24a.Far All Wells: Submit this farm within 30 days of completion of well
multiple welts tin all depths ifdt7jaent(example-3@200'and 2 111,9)
construction to the following:
IQ.Static router level below top of casing: 1 0 O 9 (ft,) Division of WaterResources
If water let-el is abase casing,use"+" ,Information Processing Unit,
- 1617 Mail Service Center,Raleigh,NC 276991617
Ii.Borehole ditnmeter: lD ZS (in.) 2db.For Infection Welts: In addition to sending the form to the address in 24a
Li.Well construction method: OZO12— above,also submit one copy of this form within 30 days of completion of well
(.e.auger,mtuty,cablc,dtia-t push,aG) euu5[inC60u lithe following:
FOR WATER SUPPLY WELLS c ONLY: Division of Water Resources,Underground Injection Control Program,
1636Mull Service Center,Raleigh,NC 27699 I636
13a,Yield fgpm) t) Method of test: (1 1° . 24c.For Water Suppyly&Infection Wells In addition to sending the form to
the address(es) above,also submit one copy of this form within 30 days of
13b.Disinfection type: 1,1 I 61 Autouatt VI.I ck completion of well construction to rile county health department of the county
where constructed. I