GW1-2022-02962_Well Construction - GW1_20220302

WELL CONSTRUCTION RECORD(GW-D For Internal Use 00.:
1 'ell Contract r nformation:
mC 6�.J1 WAS' K WATER ZONEs
Well CommetorName MO.jt TO DFSCRiMON,
23�0.--� �. .
NC Well Contractor Certification Number 15.OL TER CASING iftr multi-cosedweIIs OR L- 'M iffaftfienblel
FROM TO DiADVIETER- THICKNESS MATERIAL,
t3. ft. fa.
Company Name ,,�` /7 IrLIN?YER CASING'OR T[IBING.' thermal claied4obtil
2.Well Construction Pernut V y 9: R 0 ` 0 U 319 FRoal TO I DIAMETER TH►CtaTM A AIATERiAL
List all applicable rill owsintairm reruihx(i.e.VIC.rutm(r.Stare.t ariaikv.etc./ i, 2 fL 3(0 ft 1+5 J PVC,
3.Well We(check well use): Sl fL 6' ft. SG%k 1PUc—
lYater Supply�Yell: 17.FROM TO DUMETER .SLOTSIZE THICKA'ESS atATE— AL
_�Agriculttual Munici blic -
_ _ � p 36t1. its � m.
Geothermal(Heating/Cooling Supply) DResidentiai Water Supply(single) R ft. in.J
IndustriaUCommercial [Residential lbaterSupph(shared)
' i&,GROtIT.
A
lrJ'i i011 - - - --. FROM - 'TO - AtA - E1I/PLACE1t£NT?fEfIIODdAi1JOU\'T Non-Water Supple Well: 0 tt. ` ft.
Monitoring ",Recovery IL ft.
Injectionwell: fl. %
Aquifer Recharge QGrounduater Remediation
]%:SANDIGRAVEL PACK fifimblitiblil,
Aquifer Storage and Recovery OSalinity Barrier FROAI To f MATERiAL T imtPLAcE%uzJ%T.%wmn
Aquifer Test 0stormwater Drainage 3 k a• .5 2
Experimental Technology OStibsidence Control
,Geothermal(Closed Loop) DTracer 2MOL DRIULIAG'LOG tortach additiongabeetsffaeee�a
Geothermai(Hearin Cooling Realm) Other(explain under#21 Remarks) Faont To DEscRaPrrOx eoior.haraaeu.softmk la sherasa
fL ft.
4.date Well(s)Completed:, `E 2 Well IN Row%J ft. It.
SSR..W 1 Location:
R. ti. yam, r
Facility/Owner Name Facility i .-(if applicable) O' fL
1 S3© NG ffou rcL, N C, ft. ft. -
Pi •sical Address.Chy.and Zill 7D1. ft
2LREMARIO
iYd
County Parcei ideWiication No.(PIN)
Sb.Latitude and longitude;tn degrees/minutes/seconds or decimal degrees:
(if wall flellLone Wong is sutficiem) 22.Certification:
W _ 2. 2e3 22.._
6.)s(sre)thewell(s)�ermanent or DTemporan S;gitature certifiealYellConAmctor Dote
1)•sip tg this farm.I/trrehr c¢nrfj'tha the uvff(.ir)rim orerv, c mctntrred in accardwive
7.Is this a repair to an existing well: �]'es or �lQo tsilh%S t.A�'�I('03(".D10o r r 13A KCAL D2('.0 2 6 0 11141 Conmrwimi Srmtduntr mrJ that a
lfdift is a nparr fill an ktinim irell cmrst udimi lnfanirairon said evddin.the mitre ajthe cap'afdirs riecbttl bud heat praridecl to hell miner;
mlmirmt&r 21remarknrmilanaradw had-afthisfonn. 23,Site diagram oradditional,iclldetails:
8.For Geoprobe/DPT or Closed-Loop Geothermal wells having the same You may use the brick of this page to provide additional tc•eil:site details or well
constriction.only i GW-1 is heeded. Indicate TOTAL NUMBER of weils construction details. You may also inach additional pages.if'necessary.
drilled: SUBMI[TAL INSTR11CT10ftS
9.Total well depth below land surface: ... (ni 24a. For All Wellae Submit this;form within 30 days of completion of well
F ar malii/de u br lief all depihr ffdf•jJertimt("mm#e-3(u12W'and 2@100n construction to the following:
10.Static waterAA
level below top of casing: %—` A) Division'of Water Resources,Information Processing Unit.
Ituwer fare/1s above aarin&me••-'• 161
17 A1611 Sert tce Center,Raleigh,NC:276"-I617
11.Borehole diameter: in.) 246.jor:Infection Welts: in addition to sending the form to the address in 24a
12.weli eoastrucdon method: lox above,also submit one copy of this form%ithin 30 clays of completion of%veil
AQ
(Le,auger,rdtan,cattle,direct push,etc.) construction to the following:
Division ofWater Resources,l nderground Injection Control Program,
FOR WATER SUPPLY%'TELLS ONLY- 1636 AIWI Service Center,RaWWk NC 276094636
13a.Yield(gpm) Method of test: 24c.FerVater Suppl &Iniection Well -1n addition to-sending the form to
the addresses),above; also submit one copy.of this fort within 30 days of
13b.Disinfection type: Amount completion of well construction to'ft county health department of the coul+Jty
where constricted.
Form GW-1 North Carolina Department of Entimnmental Nis7fir.TYMcinn of Ulm—Reanmwa '?_»_antc