GW1--04115_Well Construction - GW1_20240712

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WELL CONSTRUCTION RECORD(GW-11 For Internal ilk OnI1
I.Well‘�ac fnrnw
C 1�.Y1.#TM:R%ANES
FRr i it
r� DESCRIP1 _
-cn Conttacily Name ' ft 1 9 5- fi s�,p
5s �yy - 7 ft' 1 7.; h /.)�
NC Well(:(anraclor Ccrtiticalron Number H/ I ,
�/ / 15.OI.TER C.a.SINt.(kw multi-cased wells)OR LINER Atjp! ei$e).
nr �`M�Z.,nEJ /JY� ]• F'Rll\1 lt, l 1)ILL11111( 111H'HNESS MATIRIAL
Compam Name i.,._.
If.INNER CASING OR TUBiNG(eruthermal daard-teop) fog
2.Well Construction Permit t: b mom I To DL%MEIEH IUI1(1:NFS.S MATERI.ti
I.trt ail applicable deli a,rr.sonetn s I„gnats II r I It'.1.oonw..,'tale.I arian.'.ra.. ft. ft. ,n
3.Well Use(check well use): it. It. in.
Water Sapp!, Well: 17.SCREEN
mom It) DLIMET►7t I PILOT Sin 1111(k.Ess M1.Il:RlA1
Agricultural ❑M tclpal./{Tibbs It. ff ft ,...2 in O 544 .. —
•Geothermal tiieattngI.i,oling Surrk, fekesidentud Water Supply(single) rt. ft. in
tn,lu,tn.,IV.wan cr.tal Ellcsr\L:ntial Water Stippl} ,. if.GROI'
h:uedl IT 1
'1111`1110n IROSI It) klATr,RJA6 EMkM A(-IAII'S I MFTiIOD SI a AOtT
Non-Water Supph Well: v ft 0 it. 11 /
islotlit.,ring ORecos rt. rt.(f Y
injection Wen: h h
•Ayutkt Recharge t rroutltlwatrr Remediatrtsl
19.SAND/GRA'VELPACK Of aD•ikaEir)
al:\.ptiftrr Storage and Recover\ 0Saiinit\ Ratner FROM to M.%T'RIA t I?IPL.1('F]1EN'T Sit I Ill 114
IIge . s9h 73 h .? W✓
ulfiYTest Stcormty°atrr!haulage tit
Q1ixperintoitai lechnolrn, 0, silence Control ft h .
,aothrrnud tl l„s f,1 I race 20.DRILUNG I Ot (attach atdditional she is if neerour4•) F. s,.�'`.e L s/, L.,
B.
ieotheimai ilieaun ftwo in,its:air. ,rt-) trR(ISI It) 1 DE.w RuPtw'.troloe nca...wt r'''.tops gran mac,r1..'
(t i E tlxr(ex lain under p I Rettari+t tl2 ft h �j/ y� • 'r° JUL 1 2 2014
4.Date Well(a)Completed: lip� Well ID# ft. `a� IL K� //ll '■�
a Well Location: ft it DwC.YS
t�w�� ' C' t ft „ 5-ft- ,1Ch $
locum/hsner Name lactltW lb=III appla.tb4; 36 ft. y� ft. J 4
t 0J ` iwIv 1'NV c: N 1 ,4 • ye, " 7, h .$' —
t>r.•., a A;t. , l ITN nod' r • ir. ' t n. ft
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CAY - n.REMARKS
Count., Parcel I..•,aititatinn N. t PIN, , tad eQ/ ( or 4,i,..0
fib.Latitude and longitude in degrees/minutesiteconds or decimal degrees:
lit Neil field.one tat long i,ss,tt is rcM t
22.Ccrtiticril' .4, .
4.Ikon)the wells) ernuutent or �Tempurtan
Signalu of citified Welt Contractor fine
lie aiming lags form. I;works cern/i ihut die well a t was(were,crmrtneesed in a car truce
7.Is this a repair to an existing wen: a Yes or Io with 13.1 M'4C 02C WOO or/S.i.V('.4('Oh' 0200 Witt Construction Stw.kw,[s and lags a
(f this it a repair fill ow ba+wrt well.nne:ructi:at in f„raruio t and explain the.tatun•„f the cops•oftht.s record la)s been p.rnatkd to the well owner.
repair wukr.':I nvrntrk:s+iYriOlt or.in the hack of lit.j„nn
23.Site diagram or additional well details:
You mad use the back 0l this page to rn,yide additional will site details or well H.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the*ante
cunsintcliol>,Dols 1(W-I is noels-d Indicate T17fA1:NI!M}31iR of,sills c(xl,ttucnun details You mat also attach additonal pages it neees city
dolled. /� SUBMITTAL.INSTRUCTIONS
9.Total well depth bekw land surface: -; (n.t .1ta. For \II H ell,: '.dlimit this form within try dos, of completion ,,1 well
Ii,r multiply wells lest al.kptlu if driferrnt rr(ample-i rt:On and:.i IOU)
'wing
Ill.Stalk water testa below tap of casing: tfl.) Di.islon of Water Resources,Information Processing lash.
!f water l n eI t,ah.me rasr.(c ass �' 1617 Mail Sergi ke('enter,Raleigh.NC 27699-1617
11.Borehole diameter: 10 (in.) 24h.for Lniection Wells: In addition to sending the barn to the address m 2-la
�.�s ,f ) _ allots. also submit one cop\ of this 101t11 within 3ti days of completion of well
12.Well construction method: / )1.1 � loin Inu:Uon to the I.,llnutng
(i e auger.nIars,cable.direct push at i
Dhisian of Water Resource,Underground injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Sen ice Center,Raleigh.NC 27699-1636
13a.Yield(Rpm) Method of test: 1c' 24c.for Water Suptits X Infection Hells: in addition to sending the form to
the a.i,, of this loom withpn 30 days of
13b.Disinfection type: /�'• Amount: .2 ''- ctxttrlcl: 1.., .,.' tep:(ronent of the county
whcre constructed
fisrmCIWt `:r,nh Con'I[Mt ikrytnment.:I.I ns,mn,nental Outdo s.Do.i.,onof Water Re\.;..'. Res tsed:-:2-:416