GW1--06874_Well Construction - GW1_20231030

f_.- i stilt i IA III
WELL CONSTRUCTION RECORD (GW-1) For Internal se Only:
1.Well Contractor Information:
N.103VM SOY\ l-4ly bSC?r- 14.WATER-ZO - - . - , ' - :. - - -
Well Contractor Name FROM TO DESCZIPTION
I o°�3 r 0 ft. 3,, ft . 1 CO(�*)
NC Well Contractor Certification Number 3oZ ft • 0 ft Imo,l ��
15:OiJTERCA I G(fotmulti-cased"wells)ORLINER'(if an-liable)- " _
, 1 �(� J�`� I � FROM TO DIAMETER THICKNESS MATERIAL�I I �/�J LJ \ � ' ft. ft. In.
Company Name toe,D t� U p 16.INNER CAS I G OR TUBING-(geothermal closed-loop)
L
2.Well Construction Permit#: A ad^ o ry I FROM TO DIAMETER. TRICICNESS MATERIAL
List all applicable well construction permits(i e.UIC,County,State,Variance,etc.) O ft. ft. /O l�;2 —1n. �,- z` P
3.Well Use(check well use): ft. ft C in•
Water Supply_Well: 17 SCREEN '
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Mt Agricultural DMunicipal/Public n, n• : in•
I,Geothermal(Heating/Cooling Supply) f IResi,•:,al Water Supply(single) ft ft in.
NI Industrial/Commercial Ki'esidential Water Supply(shared) 18.iGROL1T ' '!
'Irrigation FROM TO - MATERIAL EMPLACEMENT hIETHOD&AMOUNT
Non-Water Supply Well: -- - Q ft- a 6 ft• bk Eo,v-A Po a_
M'Monitoring EiRecovery ft. ' ft. • .
Injection Well: (
ft. 1 ft.
*Aquifer Recharge !�—GroundwaterRemediation
19 SAND/GRA PACK(if applicable)
MI Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
MI Aquifer Test EjStormwater Drainage ft. ft. I '
*'Experimental Technology D Subsidence Control ft. ft
®I Geothermal(Closed Loop) DTracer 20:DRILLING L OG(attach additional sheets if necessary) .
Mt Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM TO' DESCRIPTION(color.hardness,soNrock type grata size etc.)
6 ft 9 C ft Cl a y/6trnrhtkrcWn.
4.Date Well(s)Completed: )0-1) 22 Well ID# 14
c ft. re r1 tPe_._
Sa.Well Location: b?i Vet, 1*/411 ft. ft.
M o uvN! fi uv�., L LC. ft. ft. R>.: ' .�' •^e `...1 4d P^...3
Facility/Owner Name Facility ID#(if applicable) ft ft.
g
to 11 I,t; 1\ is m C C,\ C o k 0��•1 Pr Ssah o iteS4 ft. rt OCT Q 2023
Physical Address,City,and Zip a�lQ A ft. ft. If�iCl; F.;f^tl ?;-- `%r�;.:,g iirl
\ y I vapt. gS 1 5`In-10 3 o-oaD-21 REMARi{S_< :: _: - ...' . : - ~ •ir
County . Parcel IdentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(if well field,one tat/long is sufficient) 22.Certification
35. aa3' 39N -8-d. tpck_g6 r9a W
6.Is(are)the well(s) anent or Temporary 9..,
ertifi .weu con ctor Date
By signing this fo t,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an Blasting well: Yes or o with ISANCAC 02 .0100 or I SANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record as been provided to the well owner.
repair under 421 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary-
drilled: Ci7RMITr-AT.IT7Q'r�UCTr[INsl
9.Total well depth below land surface: (' 5 ( ) 24a. or AI , �lls: Submit this form within 30 days of completion of well
For multiple wells list all depths iIdifferent(example-3Q200'yya�ndd 2@I00) construction to .=following:
O 10.Static water level below top of casing: ATV (ft.) Divisi tt, of Water Resources,Information Processing Unit,
Ifwater level is above casing.use"+" 16 7 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: f 10 .a (in.)
24b.For In cell+n Wells: In addition to sending the form to the address in 24a
12.Well construction method: UC Q above,also sub it one copy of this form within 30 days of completion of well
(ie.auger,rotary,cable,direct push,etc.) construction to following:
Division of ater Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ft 1 6 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4 D Method of test: . COIli aunt.t Z4c.For Water a I & t-ectil n'Wells: In addition to sending the form to
the address(es) bove, also submit one copy of this form within 30 days of
13b-Disinfection type: iorl t‘_e_ Amount: 1- completion of w II construction to the county health department of the county
where construct - ;
Form OW-1