GW1--06892_Well Construction - GW1_20231030

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CA ylek i s,cwlr\ at. be / '14.WATER-ZONES. _ . - :i •,. . - - •
Well Contractor Name
FROM TO DESCRIPTION
�� 3 6 ft. --r sr" c1o�
ft. ft.
NC Well ontractorCertificationNwnber 15.OUTER'GAS1NG(forMulti:cased Wells)OR'LINER(if ap-licable)--- •
ISM �n Ep �� „ tj aLls__, FROMTOD1A11IETER THICKNESS MATERtA7.[[['���IIA�W.��d1J �sC tC/l1V /L d- ft. ft. in.
Company Name
2.Well Construction Permit#: SiO�Ej/P DIN
ER CASING OR TIMING(geothermal closed-loop)
— 0 l FROM TO DIAMETER. THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. 5 ft. G , in. S D v 2 t pVC
3.Well Use(check well use): ft ft in.
Water Supply Well: 17:SCREEN. . - - • • - . - .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
A Agricultural OM ..cipal/Public R. ft. 1 in.
ER Geothermal(Heating/Cooling Supply) Ili 1 esidential Water Supply(single) ft. ft in.
*'Industrial/Commercial *Residential Water Supply(shared) is.GROUT'' .
' 7!Irigation - - FROM To MATERIAL EMP CEMENT METHOD&AMOUNT
Non-Water Supply Well: G ft. , 4 ft. ®iz_ qIn „ T .
*'Monitoring DRecovery ft. ft. �rV 1 t� Uwt
Injection Well: 1
ft. ft.
*Aquifer Recharge !D—GroundwaterRemediation - '
'A Aquifer Storage . 19.SAND/GRA • -PACK(if applicable) - -... ' .. -. -
q and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
'Aquifer Test - Stormwater,Drainage ft R•
E Experimental Technology OSubsidence Control ft. ft. 1
ER Geothermal(Closed Loop) OTracer 20;DRILLING. OG(attach additional sheets ifnecessary) . . .
(Heating/Cooling (Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soNmcktvpe,grain size etc)
*GeothermalReturn) 0 ft. 145 rt. /aJ1 Ja�Y� ,rt�.L/'X� t
4.Date Well(s)Completed: i!) 1LP,Z3 Well ID# ft. .D ft l(,;.
Sa.Well Location: ft. ft. *, - rr', 11,;.:
bco J •C'. T Y r St'\O)2- rt. ft. Or T 2 0 2023 ,
Facility/Owner Name
� M 1/ Facilliit ID#(if
papplicable) ft @• h
C •t\S . 1 T r • L���'Grl i 1 A� ft. ft. �r.,v
(i? I li,; ..y R1-P2 i�tl~
Physical Addrreess_,City,and Zip t (8'1 3 ft. ft l
i
County Parcel IdentificationNo.(PIN) l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) J
22.Ce ;t cation
•
3St) 625 '-5c•9/76I3/IN "2 "l ZG.293Z.( Rl/ w ._ t
6.Is are the well(s) Si,—turn of eertifi •-.We •ntractor Date �' 2�
Is(are) 10 ermanent or Temporary
By signing this fa 1,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or o with 15ANCAC 02 .0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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#21 remarks section or on the back ofthts form. 23.Site diagram:or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having-the same You may use tit,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 data s. You may also attach additional pages if necessary.
drilled: RT1RMT'r-rAT. RrRtTC rICIANc !
9.Total well depth below land surface: 1 ' I C> (it) 24a. For All W•Ils: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd fferent(example-3@200•and 2�003 i
construction to following:
10.Static water level below top of casing: 50 (ft.) Divisi of Water Resources,Information Processing Unit,
Ifwater level is above casing,useOt"+"� 16 7 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Co 1 (in.) .24b.For In eeti n Wells: In addition to sending the form to the address in 24a.
12.Well construction method: t)
above,also sub it one copy of this form within 30 days of completion of well
(.e.auger,rotary,cable,direct push,etc.) COffittUCtiOII t0 following. { -
Division of ater Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 16 6 Mail Service Center,Raleigh,NC 27699-1636
•
13a.Yield(gpm) 5 Method of test: qA j. C fv\fet ilk Or24c.For W ter u 1 & n'ectio i Wells: In addition to sending the form to
/1
JJ the address(es) bove, also submit lone copy of this form within 30 days of
C 13b.Disinfection type: A\1 tuiYll e Amount: g -IaS completion of w ll construction to the county health department of the county
where construct .
Form GW-1 Neat,r,.,,r....Tlwnm.......«..on....:........-.....1 c..._,:... r,:-.:-:_ -e,,.----„--_. 1