GW1--06938_Well Construction - GW1_20231027

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1.
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WI±;L CONSTRUCTION RI;fi(YRll _ _ -
flris Enna can ha ntscd 'rsingle or multiple s�lT for 1uu:nn(I Use ONLY: - -��lls
I.Well Contractor Information: '
hellr_.,_
Mite Dean Cook ,;=-, -T z,, .,. .._T5.
�. t 4_t;N'A(LERvl:nl!7E�S ': ^
ell Contractor Name - ___._.,_________•____„-�,..._ _FROM ,..TD _ ,_DRSCItIP'r10N '" . .j'`.�-'�-•_.-.•^•
• NC Well Contractor Certification Nwober— _
#,.S O IIII,%ASTIV(r((fi� mutt c89•etllwel1s3i itafT '-r
Dennis Holland Well Drilling, Inc;. • 0A1 I_To -- Fk� rf(ijtjilr
1 _DIAMETER _ _
G.� .. SS MATER
-_" ft +4 ft _ )fit N ..
vC' E lA t
Company Name �, , r^ �� „ .
!ti ihl* t c ASfN(.OWZOI1IN�(geo�r,-boron'cl' ko � `-r',
.2.Well(' ` FROM 1.0 tICKN SS -
_onsfrueticu Permit#: (6�Y 7 3 •-'� .• DIAMETER' _�t71ICKNESS MATERIAL '
List all upplirnble well permits(i.e.Comity, --- -_..� - .____._.__.__. _ ft, fl. I'. ia. -_.__�_-
ty,State, Vat a,rce,/r jei won;etr':J ____.__ _
3.Well Use(check well use): •
f'_ .__._._.._•fr•----- _ '`�__'��_.__. __ _-�_-... -
VlaterSnppj Well: - ..�,_�,._.__ __._.. __..__._��—A `.17:<S(RF.FIy .r r, -:;: - -
Y FROM -... r0 Y •T%` .,... - s :.,
1'_lApriculhrral - - •.___, DIAM FTtRI .SLOT SIZE__ 11IICKNESS i4 fMATERtAi.
I:JMtmioipaVPublic rt. It. in.i -
f_7Geotlu:nnal(HcatinPJC:oolin>Supply)II �' _--•-._._._.,__ i. ._.__. -
b l l y) fil'Residential Water Supply(single) ft. .__-__...____..•
❑Ind t
ft in.!
ustnal/Commercial [)Residential'Water Supply ` 18`�RO�4JT --,
[71rripitiott (shared) FRont To F
� _ __,. _- MATERIAL_FMPrACFAfF._KfMF1NOR&AMO(INT•,
IVnu-WatrrSupply Well:— - __ ______ ___._..____.._. _.___- IL
_Nou-, itoring -- ...__-_-:- -� 4t24:.:t ry
[)Recovery � ft, . h, "_ �'�_ ._�. .
Injection Well: -,-_--.--.._,_._- .-__.__.____.-- -_ _.r- -64.0 _ft. zx %zfY_�? ' a, r �t
f.7Aquifer Kechtrrgc ~ft• rt• r1r1l._
LlGrouudwater Rentcdiation i1.9 SANK% I;AVEhiPA'�i'fZr'i r
• DA alter `t 11!>lilicati3e'` ..r;;'
q Storage and Recovery °Salinil l3az ie `FROM Tii Z` "''J?``' Eprr -._._
y rl,r AtATENIA[• I,EMPLACEAIEI`Thi1tF,'17i0D�•
°Aquifer Test ft. _..rl
OStorntwater Drainage .--•-_.- _ - ___ •-
f_7Experintental'fedtology (:)Subsidence Control •
R. n. j. _--_- ___---_____-..
°Geothermal(Closed Loop) - ......... .•. °.".n ,.""'
;tw20 I)R1L'IfNcy I c)U`(affliri1;110d111Urta1 9I1CCf8 IfinCf49a11 L
p [.I'I'r(rcer .FROM TO .. :-:.J
I:JGcothermal )-Icahn CoolinaReturn) °Othei(explain rfnclorfi2I Remarks) U&Sf RIPTION�colorJhanloeas aorUrockiYlx�greo+ru c.Z F
ft. ft. " I
4,Date Well(s)Completed:
So,Well Location: _ _ + _ �^_
I."<s:.�-_ zza4---1.& Tc:'ltt>yF_ ?-, 6-2 ) 7 ;2.i 1 ft. rt�_ - �,.,` ?;y "e�Y
Facility/Owner Nun - ---
Facility lDll(if applicable) -___...___...._...— _.__..__.._._.,__--------_-._
Physical'Address.City,and Zip �'_" - ----- rt.
t rt. I
1.• ?.1 s12FMA`1iKS ? Ift,v+.r, = I�• f, .
County - , ___. _._.._._.-_ ._._._ ;._<_ .---•----_._ .___
Parcel Identification No.(PM) • — _ -
Sb.Latitude and Longitude In degrees/minutes/.seconds or decimal degrees:
Orwell field,one Tat/long is sufficient) 22.Certification:
3 j- ____-_2r 5 `' N >e ao ,. ,,ram▪. !'
r�,�-• Signature of Certified Well Contractor Date
6.Is(are)the well(s): {A•Pcrmattent or OTcmporaty
By signing this form,I hereby rerti(that the"well(,)was(were)constructer'in accordance.
with I.SA NCAC(12C.0100 or 1.SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: CIYes or 1-6--
copy of this record has been provided to the well owner.
If rids is a repair.fill out known well construction information and explain the nature of the
repair under'/2/remarks section or on the hack v/thisfonn. 23.Site diagram or additional well details:
You may use the back of this page to'provide additional well site details or well
• _______ -_ cnnslnuaiun details. You may also attach'atlditiunal pages if pert nary.
S.lNumber of wells constructed:
For multiple injection sir lion-wales supply wells ONLY wills Me same consharlian,you can
sr,b»,it one form. SIIBMIT'l'AL INSTIICTIONS
9.Total well depth below land surface: ,j ^ymm ,.-�_T�(ft,) 24a. ,FOLAIl Wells: Subntit this lino,within 30 days of completion of well
Formal/0k wells list all rfeprhsIf different(example•3®200'anti 2@/00') construction to the following: I ,
10.Static water level below top of casing: „ 6 ' ^•(ft.) Division of Water Resources;Information Processing Unit,
((wirer level is above casing use" " - �
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole.diameter;� ,_P________. (in.) 24b, For Injectiou Wells ONLY: In addition to sending the form to the a(idress in
Rota► 24a above, also submit a copy of this'fin in within 30 days of completion of well
12.Well construction method: y___ __--_ ...-_ .•_�"'•_"-� construction to the following:
(Le.angel,rotary,cable,direct push,etc.) •�-
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FOR WATER SUPPLY WELLS ONLY:
Division of Water Resources,'Underground Injection Control Program,
�� TR 1636 Mail Service(;enter,Raleigh,NC 27699-1636
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13n.Yield(gpm)_..__1,. •_,.____.____. Method of lest: Air lift 24c,For Water Sup,p &InjectionW Ills:
Also submit one copy of this form within 30 clays of completion of
13b.Disinfection type: H H Amount: 12 0l. well conbinrrtion.M the county health idepartmenl of the county where
---- -_ -__— _—_ ._ constructed. t
hone G�V•I Nnnh CarolinaI�rnarhm:m of Inv, I u,.,,,,.,.,I A,,,,,.e,'rni t.