GW1-2021-01689_Well Construction - GW1_20210322

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WELL CONSTRUCTION RECORD(GW-1) I or Internal Use OnIN-:
I.NN'ell Contractor Information:
1^C
'Famish \ 1� V son 14.%%AI ER ZONES
FRONT TO UF.SCRIYf10N
N'eI lConu'ae(.lr Sam 11Je ZQ�I. 0 f- to w
���^
�3 `[�11 ft. ft.
l
NC w ell(Tmus da Cenitiomion Nundmr IS.Of"I-ER CASING for multi-cased wells OR LINER ifs livable
NO UUNIk 1 ER HI(A\F55 MATERIAL
ft. ft.
Com,tons'\sine ' I n.
iND�GI 16.INNk:R CASING ORTUBI\C eothennel dosed-too
2.Well Construction Permit k: �( FRONT TO Ur{MkSFR 'fI11CKNESS MATERIAL
I.orall epp..ahl, gall rou,Iru.nm...... O.d. UI('.('mm�r..bnrd. Imaan.e_en.I ft. ft. In
3.N'ell I-se(check well use): ft. ft. in.
17.SCR F:f:N
N'AIPr$UppIV R'lllo FROM TO DONIk IER SI.OI'SI/1: I'1I1(kNFSS MATERIAL
Agricultural �Munla , 'abbe ft. it. in.
Geothermal(HeutintrCoohng SuppO .tdellual ll der Supplv(singla) R. ft. in.
Industrial/Commercial E)Residenlai U'acr Stili (shared) IS.GROIT
Irrigation FROM TO 111HR111 EMPLACEMENTMETHOD&AMOUNT
Non-N'aler Supply Nell: If f6
Monitoring Recovery H. ft.
Injection Well:
ft. (1.
Aquiter Recharge []GroundlNater Remediito
E
SAND/GRAVEI,P.ACKIifa ,
.Aquifer Storage and Recmer n$allll, baRRr FROM TO MATERIALlicablel EMPLACEMENT METHOD
Ayui ter Test nSlonnuater Drulnuae ; I
Experimental Technoll- Subsidence Control C. ft.
GeotheOn al(Closcd loop) �l7acer �120.DRILLING Lihimch addirional sheers if necessary)
FROM T(/ UES('NIPTION Irolor,hardness.soiLiakw u<,em.
Geolhumal(I lcatoocC'oolin_RsunU Other(c,Nplam under 021 Remarks) 1;�� ft. 51� ft.
4.Date N'ell(s)(ompleted:d-i—Z► Well lDk in. ft.
in. ! ft.
5a.NN ell Location:
-non �S aS
Facilitc Owner"Neinc 1J I'v.ihn ID=1 `,pplkhblc) 1'L �.-
11"I T01.rri Uir ire L��c�skp� NG jS1�f�
Phcsical Address.('ite.and/n, D. ft.
n i NCfsM Q Jpp NN 170D51VS 00C>0 11.REM IRKS
l� � l lY.- . nnll
Counp Pamd Id,,,iuicaliun A'o WIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
lifwdl licld.one hit Ion,iautlicicnu 22.0 rti alion:
35°39' 2J4'•I99"' N 8;?& -AI -it-IN " W
6 Is(are)the welhs)� ermanenit or �'1emporarc ,at ( ft 1N H( Dv
Ynho / 11 hf ma'a 'G.a F I - -.I "I �rdnnce
7 is this A repair to an existing well Par% or E).No Ir A 1 "('.olou 1i NY At r t 02061 /r r ..non Sit ularJ.and,hara
/fIh. fill +I o ,.//o I...Iiw.../ r r ..../,.,hoar rhr numr<o/Ih, 41 /rl I'll haeh P 'i I'll d 11 we 11 IP nuuc
r n�anr/er-d/runrod arovar or olr rh,he.kul//.. rm
23.Site diagram or additional well derails:
8.For Geoprobe/DP"f or(losed-Loop Geothermal 1Aells hating the same )'ou max use the back of this page to provide additional well site details or well
constriction.onkI (AN-I isneected. Indicate 10'1 Al Nt %I HERot ,ell, ZOnStroCll.andetails. You min also attach additional pages fnecessary.
drilled. St BMII 11:M.1N'S'1'RFCl IONS
9.Total well depth below land Not ace: ,-)U A) 24a. For VI Wells: Suhntn dlrS form moron 30 days of completion of well
F-nnJup&u'rIL.fin,nit,drprh,it Jdlecnr nvnnph-3§d'o0'ea..`u ion', eonslnleaon to the follofcm,,
10.Static water level below top of easing: I�I) (ft.) Division of Waiter Resources,Information Processing I.nit,
It......lyre/t,oho„Darr....r" 1617 Mail Service('enter,Raleigh,NC 27699-1617
11.Borehole diameter. (o a 2 5— (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
2a+rru above also submit one copy this form within 30 daNs wcompletion of well
N 12. 'ell construe lion method: ;onstnraion to the following
1 i.e.auger-mti ry,cable.dlrcc,push_etc I
Division of Water Resources.Fndergrimnd Injection Control Program,
FOR WATER St PPI N N'F.LLS ON Lit'. 1636)fail SerN ice('enter,Raleigh,NC 27699-1636
13a.Yield(gpm) 5o Method of ost-Joil. CAMIZt;n1file 24c. For Nit mer SooDly & Injection Nit ilk: In addition to sending the form to
/� � p J�a ,. ;hc add:c.,l ts) aboae. also Sohmit one copy of this form within 30 days of
13b.Disinfection rApe:cik, /`t Amount: 5 -Oiroamn of well constracoon to the count, health department of the county
where ttmst nlded
Fom,G W-I Nonh(-tin+ana D,enmem of ltnmmiiumum.Quad.,-Un smn of Warer Ilcsoures Revised 2-22-2016