GW1--01785_Well Construction - GW1_20240320

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" For internal Use Only.
WELL CONSTRUCTION RECORD(GW-11
I.Well Contractor Information: —
tt WATER ZOYFS
pt lA ritOm DESCsrncm { fl--&"
N'ci!Conms.lor Name IL NC Well Conw:S>t Centii,e,on NumberkL _ JQ iS,OUTER CASING Coif multi<aed w-----db UR LIYjCR.if t••litibit_i
p (� !!!���,,, DSAAirrsa T)Dtwx5 ss�
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Company Nana ��� rjf i6.t®:AS1N�G OR Ulirh®aT1414 wY[BS �,ts.a+.vs'���`
f. r !� 6 t
2.Well Construction Permit 8: P ws (7`Q ft. ft, sn•
Lot all applicable He can:rnn non IrrmLt Clay WC.Leann•.Slam.Varian/:r.:rr) la. —
ft. ft. ,
3.Well Use(check well use): s7,SCRLEN " •r
FROM TO 4 DIAaII IEa SLOT Sllt� THICKNLV.
Water Supply Well: r O f 'M;�
Agficulntrolicipal/Public ��(L (DO ft. to_._�._-Y7 _.
_ Geo
thermal(Heating Cooling Supply) esidenfial Water Supply(single) ft, G. 1S f
Water Supply(shared)
Industrial Commercial ['Residential . .t;RbUT. - • "" p4irt icrnser.tT+it stbDh a-�t ="+`r
Irrigation rROM TO 61A71.RLA1. �
a(Q ft. petlwe-c __pout'
Non-Water Supply Well:
hlonitonng ARecovery n. ft. _
Injection Well: ft. ft. _--
Aquifer Recharge ®('nuondu alu Remtd f7u,;i Oh SAND/GRAVEL PACK(if applicable) —1
A1Al LiO AL imrtC \ T NF'. —
Aquifer Storage and Recovery DSahoit)Battier mtovt to — tE\t+
Aquifer Test �StonnwaterDrainage �.<� rC 6p ft. #-�SRf1d .__Cl1_____
Experimental Technology Subsidence Control ft. n. 1
Geothermal(Closed Loop) Erwin Id.DRILLING LOG Gtach additional Oros it rereatan)- pea x•a.,_
!'xON TO DESCRIrn bs,UN ho Mars.re,. n.rart to m sire,Net—
'..
Geothermal Heatit rCcoiin Room)
�l Other(explain under N21 Remarks) 1 (, Ho ft, �AFy ^
. i.Date Well(s)Completed:�-f^I-019 Well h1)I .11O (t. /q C.) IL VY)e U1?'1 ( -ray .,- r/od
'i: +l. ..�.:.,
v ft. ft._ 6
Sa.Well Location: it. R. f.'.
SNC\wn Fo S"re C _- —
Iacllo (Mtet Name 1`Ai ally ID.(+f sppixahie) t1. ft. a> t
3039 COB sc \ ecV F ACM ville, V.Ct n. n.
Phoical Addtns,City,arid Z,p _ ._ .__ >•
Pot- 21..REStARKS �_�—
Camry Prrccl lac nntit'atu�.n Se(1'iNl J e-1-__.`CC t C K.. l:- O L 1-_ __._...�__._._.._.........�-'I
Sh.latitude and longitude in degreeWminuteslsecomds or decimal degrees: _._v
0(.01 field one Le Song is sufficient) 22.Certification:
TS 6/3 Lt g N . )7 'Ago 3)-, \ W (4.4,(....dir , -ii..„)
6.Wart)the selt(s) Ptrtnaaent or oTtnaporary gs.anrrc of Certified K'el!Contractor �u
By signing tilt form.I herebypewits that the ee/ltr)cans frere)cunstrr :»u ctrd an assursL
7.Is this a repair to as existing well: 0Yes or rpm,— with 11d ACAC-we 0100 or Het MC.tC 02C 010)Well Conrawtan Ssonsdards and tier al
tl WI tr 0 rryrtu,Jul rrnt an0»A 441 coal frs Jon tn)WAatsan and esplaaD the netrar of inc •' ' - iM1v
re• pair wrier r11 remarks section ore!an the tru of this Corm. 21.Site diagram or additional N ell details:
8.For Geoprobe/DPT or Closed-loop Geothermal Wens having the same You may use the back of this page to peas ids additional well site details of well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details You may also attach additional pages if necessary.
drilled: r SVBSiiTTAI.INSTRUCTIONS
9.Total s r v
ell depth below lend surface:— v (fl) 24a. For;ill Wells: Submit this fora wi:hii 30 days of completion of well
1•'or mt.lttple sr11.1 lass all depths 1(d;Qoent fesanrple.14200'and 2: IOJ) construction to the folic»tang:
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10.Static water level below top of casing: I . 0
(IL)
Division of Water Resoteva,Information Processing Unit,
(f watt.!cart at choir raaag,sst''.' 1617 Mail Service Center,Rs ieigh,NC 2 7 69 9-1 61 7 •
11.Borehole diameter: .•E (in.) 24b.for Inlectinn Well!: In addition to atoding the form to the address in 24a
12.Well conslructlon method:
'PI) 4�Q
O above.also submit one copy of this form with completion in 30 days of completio of well
1��
Cie.auger,'cosy,cable,avert pmik sic.) construction to the following,
Disislun of Water Resources,Under grcland Infection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1616 Mail Service Ceutcr,Rdel.gh,NC 27699-1636
13a.Yield(gpm) 15 Method of test: f t t �' Fuly.� n �\r : am the rth to
r the24e.uddresstes}\Toter about+ve, also sub]eetion mit one espy of this ion forth witdinghin 30 daysfo o
13b.Disinfection type: --kIn-to Amount:_3 Q _ eompleorion of wellS constnsctiInn to the colhtnt In healthdd departmenttosen at the coumtyf
where constructed,
Form GW-t // North Carolina Deparnie of of Enriionmcntai Quality•Division of Witty . Rastsed 2.22.201Is
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