GW1-2022-03362_Well Construction - GW1_20220314

Prinf Form
WELL CONSTRUCTION RECORD(GW-1) For Intcruml(,se()Ifly:
I.Well Contractor Information:
f
1, 14.WATER ZONES
WCIIConmj,w NL,71. R t I 1—11—1
ft. ft- j,r
ft. .: 11. 1
15.OUTER CASINC for multi-cased wells)OR LINER ffapRlicabje)
ft.
Coavrany Name
16.INNER CASING ORTUBING.(geoth r .1 losed-loop)
Y.Well Construction Permit USACE-FUDS Site
Lm'fl�4w!"dble�,,*I on.......I p,—w,0" �—4 "-Cowen Id,1411, 1-:1 j
ft. I
-------------I--
3.Well lase(check v ell use): ft. ft.
uter SupplY Well: 17.SCREEN
ro
Gt-olliernial(ljcjttir,.!(',IolIIjL,Supply) It 17� In j�;'..6/o 15�e.� �o, 1 /VY,
Residential Waie:Stlppl� J;"
IndusiriaH ollimcmid [3Rcsidcnm,l Wam Supply(shilleki) -.1--------it.—(;ROU'l'
NIAT VAIPLACENU-NI.
N VV VIIIAL %IF I HOD&ANIOUNI
on- atcr,supljl� Well: D. bl:-,fa-v
I
I
u n t
d r I U"tu r.0
p
L L r
0
\P R�E-
a Sol),
\'41
Rvcoveiv
- I 1 0
Injection Nell:— -f- -ee
F_x
Aquifer Rechaque Retlic,li,ition 0 3 Co""t f-q
't 19.SAN A 1,PA(."K if applicable)
Aquifei Stmage and Recovcn DSafiniiv Banwj
A, ilia test DSIornmater ft. ft.
[DSubsiden,;e('onilol ft.
:3Gcollicrinal(Closed Loop)
1-mcer DRILLING LOG(attach additional sheets if necessary)
:jGcodwrinal 111calinpCooling RCILII-n) [701hor ic�plidn mider 421 Remark,) IlRMI It)
ft,
111.s'KIVI 11",
y
4.Date ell(s)Completed: If-2-2- ell I D'I M Z6 ft-
5a.Well Location: '2 2-C' ft. SJ� ft- i Sr C
/I?m MCX--,-L1A/ 7 C u- If
M-7, "-' 11"' 1 -. -",
7q ft- f-C If
-Le 6 7 u(j,e,., -
e7, -�C,�e
A.
—A ot
Parcel "—PlN)
it).Latitude and longitude in degrees,roinutesiseconds or decimal d
22.Certification:
N (YC'- k 3 3�/
6.Is(are)the vell(s)OPermanew or 01'emporary of(ewf"M w6f
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7-Is this it repair to an existing well: C]w% or RNo qh '51 V.V 0 01'Y", 1i"1 4( 0 0200
........ .fiq,Mh,r and,'14"t, h, r„ri-
f,".!0 rho" ,� ,,I ha,
23.Site diagram or additional tell details:
8.For Geoprobe!Dll for Closed-Loop Geothermal Wells imvmu the<Ilnlc You 111,13,'ISc the back of[ills pa,-,c r,iprovidc additional hell sac jlejajl, ,,r,kjj
C,"I'l Ilwl I on.onie I(AV-! i,liccdcd. Indicitle I I-Al NI of well,
F/ :) SURN1111,11 Al.1N*STRj1A*IO.NS
9. fatal well depth below land surface: 14a. For All )'ells: Submit llli, lomi "ithol 30 djv> of compicnoll of ae!1
conmruction to the Billowing:
10.Static,eater level[)ell)-top of casing: ft.) Division of Water Resources,Information Processing Unit,
1617 Mail Service('enter.Raleigh,NC 27699-1617
I.Borehole diameter: CJ (ill.) 24b.For Inieefion Wells: fit AiLlIzion to�-,:nding the lorm to the address in 24a
12.%Neil construction method: Alme, ;I!I so st0l;llll olle cope of till, toll" within 30 days of eompleti,m ot'c,elj
(i "Mary. Ct P;.,Il rt.1 COIISIRICIRM to tile oJi0%VlnL1:
Division of Witter Resources,I nelerground Injeelhol Control Program,
FOR WATER SUIIIII,N'wEl,l,s ONI,y; 1630 Mail Service('enter.Raleigh.NC27699-11636
13a.Yield(,,,pill) Method of'tes(: 24c. For Water Supply& Inaection Wells: In addition it)sending the form to
the addrcs,ics) above, also slihnjil t;lle cope of this fonn wiIhin -'50 days of
13b.Disinfection tvpe: Amount: compUion of well orwtucnon to ill(: county health department of the county
where c,mmtoct,d
1"fill(,\V-I RL I lle:'-"-2W fl