GW1-2023-02630_Well Construction - GW1_20230410

WELL CONSTRUCTION RECORDIGW-1) For Internal Use Only:
1.Well Contractor Information:
14.R ATF32 ZONES
Well Contractor Name FROM 1 TO DES
466)7 APR 1 0 2023 Yci I 't 6-9,0 ".
ft.
NC Well Coninictor Certification Numler r)iC- !J:-a -
15.OUTER CASING(for multi-cased Avells LINER(if lica
ulli-ca"Avells) R lei
WgyZe r-IIIZI— !91 tllram fil 7 TO DIA51=11 I - JUKAESS "%VLTERM.L
Company Nam* ft. ft. in. I
16.EVNER CASING OR ING(4geothe a]closed-loon)
Construction Perntit#: wmoco 1?-3? FRO.111 I To YFJJ_CK_NESS ATERIAL
I IMAJETER I MATERIAL
List all applicable ivelicansinictioupenilits(i.e.UIC.C01111tv.Srare,1�arjajzc-e.ate.) It. ft. in.
3.Well Use(Che&Well use): ft. in.
NVater Supply Well- 17.SCREEN
FiTU-11 TO MANIFTER SLOTS17 TuiC;5,r-s s 55,TERim.
-OAaicultttml MunicipalTublic ft.
ft. itL
Meotherflial(Heatinpi'Coolir 2-
ig Supply) DResidential Water Supply(singgle) D I 5nti, LIZ)
ft. ft is
-
01ndustrial/Commercial ORessidential Watc�-Supply(shared)
(;ROL_.r
Oh-rigation 100.00 GPD FROM I TO
Non-Water Supply Well: SI fL ft (geothermal
%,Monitoring L) MIA
CY✓f"
'y"c""
ee.i e. -4riYAMlif lereo ore
ft
Injection Well- '11-6' 0
IL ft.
OAquifer Recharge IlGroundivater Remedialion
ElAquifer Storagc and Recovery OSalinity Barrier 19.SAND/GRAVEL PAC fif applicable)
FROM TTO MATERLAL
CAquiferTest UStornim.-ater Drainage 4,�'J/ ftt �S—/ rL
OF,
4
xne"rimental Technolo- CPA 4 —Jr tM(n)d.4,.:,V 1?�
gy OSubsidence Control fLn.
t[qGeothermal(Closed Loop) 07fracer 0 DRIL G LOG(attach additional sheets if necessary)
lz6d-b6thclm-I(Heatin.--iCO-Ht�-%Ret. 00ther(explain undti-=2 T R iFROM TO zim h=dn�s-Wrack qpc. l:i s_iz�7ks
10 ft' 35- ft.
T,-t
3-_�b Well IM N p�M K 47
4.Date NVell(s)Completed: I R 0/3 3o� ft- 6 t 45 rL
Fyn
na.Well Location: ft. ft.
i -e. A E, i Ve 1,er-lie, ft. ft.
FacfliLy,"0wncrName V
Facility 1130(ifopplicable) ft. ft.
L) ft. ft.
Physical Address.Cm.and Zip
YLPT002-q 3 0 3 ZI
County
5h.Latitude and longitude in degrecs!rninutestsee6lids'ordeci-r.nal-degrees-
(if well field,one latflong is sufficient)
22.Certificntion:
3S 113-, N 21 6 37 W
Cf_
6.Is(are)the weii(s). Wermanent or OTemporary Sipatu of Ccrd: d well Contractor Date
Br signing aasfam;.I jlerc.n.cerrifY that the well ft)it-as orer'-)constricted in accordance itfth
7.Is this a repair to an existing well: ElYes or JkNo
10his is a repair,fill ma Anoitv irell corn.-acii—injbrazation oral arplair-x none qirthe qf this record has bevy r,ul.,;ded it,the well all-ner.
repair under g-'I remarks secdorioron:1'1-eh:x.:q1*a1Lvjarn1.
23.Site diagram or additional well details:
S.For GeoprobeffiPT or Closed-Loop Geothermal Wells ha: the-same You may use the back of this page to provide additional well construction info
construction,only I GWA is needed. Indicate TOTAL NUME.P.-R ofivells !:Idd',SLe Ove'in Remarks Box).You may also attach additional pages if necessary.
drilled:
2-1.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For intillip!e wells list all depvLv ii-djIlle.ein(erainlyk,3L6,200 cnl 2 Submit this GVV-1 within 30 days of well completion per the fulloiAna:
10.Static water level below top or casing: .5-460 tit t 24s. For All Wells. Original form to Division of Water Resources (DNA"R.).
fl'it-ater lerel Is above casing.ase—- !"formation Processing Unit.1617 MSC,Raleigh.INC-27699-1617
11.Borehole diameter: 21 (in-) 24b.For Injection W-ells:Copy to DNVF_Underground Injection Control(IUC)
Program,16-36 RISC.Ralcigh.NNC 27699-1 636
II.Well construction method: I C�
IL
Le.surer,rolary.cnb1,:.direct push,etc.) For NVater S and 40ion-Loots RaICLeothermal Return I'yells
ve1.1; Copy to the
F_
county euvironme, r; nine",ul.the county where installed
_pa
L:
FOR NVATER SUPPLY WELLS ONLY:
24d.For'V1,'2zer "ells producing over 100 000 GPD:Copy to DWR.CCPCUA
13n.Yield(gpm) M -.L
ethod of test: E1—Permit Prc1 '. 1611 MD_ralelgl
13b.Disinfection 1_1,pc:' Amount-