GW1--03376_Well Construction - GW1_20240610

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Weil Contractor Information: [
MOM TO DEICIIMWN
Well Contractor Tame -
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tv'C Wei!Cnctracmr Catificatica Faatria -is.OurER CaS8i1C tar fa atli asni OR LI22mt(Gf )''
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Name �� 1Q l� V ' V (,
Company .I-1-I i J f AI - n?y t- WOOL r MING ORTUIt Lal l da'c+faep) -
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r.to nit nneinnleset m�®rasa n.ea I :tea:im: M,..�r 1 I - ___. 1 --_
3.Wen Use(eltecksfe8 Ds n a i•
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tT�CifZEY2f
Water Supply Weil: moat To DIAMETER SLOT SUX TtriMiMS .MATERIAL
QAgricultunl $AfcaicipaPPubliic f 14 in.
©Geothermal(HmLnJCooimg Supply) it r.•Ideotial Water Supply(single) (L f4 III.
QInduSirialiCotumari:I li Residential Water Supply(staocd) ,:safstor2r = _ r
Iihnstatim -beau TO /MP.PT IL ,yy ONL_ACEM .TMETHOD&AMOLTT
I3oft SVater Supply WelkCS✓
jManitcring f Rccontry A- R. —
Injection Wet it. At.
QAquiferRecharge OGtoundavterRisaednDae 121A3.1.3 ►tr>:1 PACK ,gira8ge) m
Aquifer Storage and Recovery OSalipity Artist' FAottt Ta II4mIai EMPLACEMENT METHOD
Aquifer Test r3Stanl erllraisige _____ _
QEEperimemml Tectindo`y QSubsidence Control ft. n
L©Camthermal(Closed Loop) QTracer 2l.^sa`rs i ING LOG t d aerial sbetIA i stmevT) _ _
FROM TO •,a.. ,• t Auks sdrkeek type,tpaia she.tee)
©Geothermal(Heating,Oxiinn Rcttaa) f lea Otber b..NpLtin der i 1 Remarks) a. 1 to &/ev►✓n (,I%
4.Date Weil(s)Catnpkted: te) '
4 ,a` Well Mg 1 a- ) a' [-NA
5a.Wen I.ocaftext: Cr ft. 5 a Ira lire,
Lcui
Facility/Onctllama ,w facility NV(if applirabk) ft. n. ' -''` -!1�l�L
Phriml Ad as,City,and Zip a. I N 1 a r4
•
Gahm' Parcel Identification o_(PP.') _.
5b.Latitude and loagtude In or&thinl dunes:
S.--2 3—8
6.Is(are)the weil(s)MPeritmrnt or!Temporary
s;gsuaae atCalifled t ell Contractor Hale
6y sgntny des font I hereby cent&that the wall(s)lids Oren)rnnvn.cted in accordance
7.Is this a repair to an edisting well: IjYes or 121No with 15.4 NCAC O2C.0./00 or 15A NCAC 02C.0200 Well Canstrnclion Standards and that a
If this is a repair,fill out known well construction lgfarnation ardexplain the nontr afths crTY of lar record hex been Provided to the wa!owner
repmr under#21 ramc►ks stale.,or tie the lwcteftlds font. 23.5tte diagram or addltleaal well details:
8-For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may cue the bad of this pate to prtsv de additional
will site details s or mat t
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells 0000°Mails_You may also aitact.additional pages it neocssary_
drilled: SUBMITTAL INST}2LTCT(QNS
9,Total n'en depth below land surface: (ft•) 24a.Far All Was: Submit this font within 30 days of completion of well
For multiple mat list all depths tfdjlercnt(example- 2/5 Ag1017) construction to the fdlouing:
10.Static Seater level below top oitastop L O (it) Division of Water Resources,Infonwntioae Processing Unit,
Ifweer level is above canoe.arsef"+w 1617 Ned mice Center,Raleigh,NC 27699-1617
11.Borehole diameter: 11 l. / (in-) / 24 .FRr jptr
ption Wellts: In addition is sending the fan to the address in 24a
subm
t' J to
copy of this formwitkia 30 days of completion of well12.Well construction method:: 4iY(ie.auger,rotary.cable,direct push,cz.) j
1inicinw ofWater Rs mgnes.IJndrrpromd Iwicrtion Control Program_
YIr-l(i.' 20 4 r jii
0,5 ' it-CR(4101 Tre , j
Chi ores ilcoi
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