GW1--06312_Well Construction - GW1_20230926

WELL CONSTRUCTION RECORD GW-1 For Internal Use Only:
1-Well Contractor Information:
Well t or\ ``6 Soh
Cont 14.WATER ZOiYES DESCRIPTIONractorblatne most ro
6 n• a
Lb q S .N, ft.
NC Well Contractor Certification Number a Marble
15.OUTERCASING formu111 cased volts OT>IILClaiESS AfATER1AL
,- <-,nt?_ �T�� * ,LI !1P 't FROM 70 DIAMETER 9 '
Company Name ui9�V v `4 4J Y 'v f1. j . t6 y s
�p ^ 16.INNER CASING ORTUBING(geothermal closed-loupes
2•Wcll Construction Permit#: 1 d 3 FROM TO DIAh1tiTTR Tm '19 MATERIAL
/
List all applicable well construction permits(i.e,UIC,County,State,Variance,etc.) (J ft. �f ft. �' in. 2,1 ` v
3.Well Use(check well use):
ft. n. In.
Water Supply Well: 17.SCREEN b1ATERIAL
11Agricultural sxonl To DI4\tSlt-n SLOT SIZE TIPCI ss
Municipal/Public 11- n.
al Geo ermal(Heating/Cooling Supply) 1DResidential Water Supply(single) it. it. in.
la dustrial/Commerciai OResidcntial Water Supply(shared) - 1sGROUT. - - NT]VIEfIIOD&MtomvT
®lili:atica FROMTO 5fATERIAL ����ME
Mon Winter Supply Well:
n. t� n. , 0 �
It Monitoring Recovery ft. ft. ("),,,ti
Injection Well: ``'"'''SS
ft• It.
li Aquifer Recharge I0 Groundwater Remediation -
*Aquifer Stora a and Recove 19.SAND/GRAVEL PACK rf s RIALe CEM&t�r.,mETnon
g ry 1[ Salinity Barrier FROM TO MATFtrAL
®'Aquifer Test DStormwater Drainage ft. rt.
•Experimental Technology Subsidence Control ft. ft.
*Geothermal(Closed Loop) IOTracer 20.•DRILLING LOG(attach addittonel'eheeta if necessary) -
ill Geoffiem1al(Heating/Cooling Return) Odrer(explain under lJ21 Remarks) OM DESCRIPTION(color.6ardaess,selltroclt 4pe,arala size.etc.)
a.
4.Date Well(s)Completed: -l'1-23 Well ID# y'ft._ ft. t ti
5a.Well Location: �� n• �• L
g•4'1-._113 a- A,Ja. t�twi R. ft.
Facility/Owner Name Facility mtf(if applicable) rt. fl. �. 4 t G° 2-^ �,
loos- 4 rsou..tt4o R- .i .s!-t 1`X. t' IL S F P 9 G 20?3
Physical Address,City,and Zip 1�,` �l R• ft.
"1-ere.a+l .r'1'',. 559�• Ci 3- f{FrZG-°Oc�l 21.-RE1IARKS ln;::, t ,J :.,. . ,F L�..
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
35° lb l l .l-(S,Si.H, V-.)°q(t j (Z 8.C•51 Ci 3 w — �-� .«
6.Is(nre)the well(s)WI Permanent or OTemporary gnarure of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or with ISANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction infonnation and explain the nature of the copy of this record has been provided to the well owner.
repair under t 21 remarks section or on the back ofthis form.
23.Site diagram or additional well details:
8-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 or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: er runTrrr f-trtc rRiv-1-1cmc
9.Total well depth below land surface: Iti�{ (ft.) 24a. For All Wells:For multiple wells list all depths ifdperent(example-3(200'and 2@a 100) — Submit this form within 30 days of completion of well
construction to the following:'
10.Static water level below top of casing: (ft)
Div[ston of WaterResources,Information Processin
Ifwater level rs above casing.use"+'• g Unit,1617 Ma[last
Service Center,Raleigh,No
27699-1617
11.Borehole diameter: tit • (in.)
24b,For Injection Wells: In addition to sending the form to the address in 24t
12.Well construction method: �� above,also submit one copy of this form within 30 days of completion
(ic.auger,rotary,cable,direct push,etc.) construction to the following: of a el'
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control
1636 Mail Service Center,Raleigh,NC 27699-1636 program,
13a.Yield(gpm) Method of test: CcJn PJL 24c-lfi e ,u I
LLi/^�� 1�� �y t the addresses) above, also submit oneeco• adhis to sending the fora!U
136-Disinfection type: L A'C511(t`�, Amount f G S wroplctres of well construction to the cow} of this form Witt 30 da
where constructed. county health dePnent of the count,
Ys °