GW1-2022-06013_Well Construction - GW1_20220621

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YY.6LriJDJ V..CYl`t1YJLJrCWK.�a��.Qi'SV 1a�]!L'eCr4U1WaY VTVV�Ilp rurilitGrlQl USUurry:
L Well Contractor linformation:
Reuben W. Cla tan, I 14.311AIMRZONES
WellConttaciprName FR01I TO I DESCRIPTION
2241 A aft. 1
fG ff. '
NC Well
¢Corit,Ir'x�ttaPFr§CQer4iafctcgationNumber 1S.O-UM CASING(for muld-casedwells ORL1NER lfap -'cable
rkqua Drill, iltl c. FROM TO DLAMEr�.. TJUCtt1YFS5 RLITLRIA6
6 ft: b•� fC �t in. - 1 �.
CompagyVame /
16.INNER CASING(313 t17B1NG thermal closed-loo 1
2.Weil Construction Pcrr.it P-. 171101t TO 1 DLAMETER I Tarr1{NESS NATEItLAL
11.xt all applicable well construction permits(Le.UJr_County,State,trarlancq ear~) ('. in.
3.Nell Use(ciieckweli use): ft. ii, in.
Water Supply Well: 17.SCREEN
FR01I I TO I DiA1LEf£lt SLOTSIEE iWI-C SIO•ESS MATERIAL
Agricultural 0 icipal/Public Q fry ft in
Qi Geothatmal(Heating/Cooling Supply) Residential Water Supply(single) ft: ft. io
industrial/Commercial (111esidential Water Supply(shared) 111 GROU
`Ilrllgation FROM To MATERIAL EE2L,LCta17ENTat7EEP.ODE�4'1LOrT1T
6Non-M—later supply Well: `� 31., ft.
Monitoring LIRecovery
injection Well:
Aquifer Recharge �IGroeadwater Remediation
(Aquifer Storage and Recovery Salina Basic 19 9.4WDIGRAVIEL PAC[:ifa lic2blel
[]Salinity FROar - TO MATERIAL EMPLACEIIENTIiE•MOD
Aquifer Test OStorsmwater Drainage % �•
.EsperimentaiTechnolog• 03uhsidencecontrol ft. fr.
Geotliurmat(Closed Loop) OTraeer 20.DRILLING LOG(attach additional sheets iFnecrssary)
Geothermal(Heating/Cooling Return) Other(e.,mlain under 921 Remarks) FROM - TO DESCRWRON(color.6ardnws,sa0hock h G ern;a se5 ei�
ny 1L ring
4.Date Wells)Completed:- o�ell iia�lr a�lJ R' ?7d M
Sa.Well Location:
� �nPS '►�' tt. ft 6
allFa
Facil�ityy/Ownepr'Name \ ( Facility IM(ifappl�ic`able)!� _t fL
�ra[()J k'ia"lIt!'^1 'd1i P��it n 4it11 IIJ� N�C'� fL I fLUP
r} d9p`.�AI�I?> Jf`1
Physical Address,Citi•,and Zip ft. ft k n y e_ E
21.REMARKS
rn_sr j �
County Parcel Identification No.(PIN)'
5b.Latitude and longitude in degrceslminuteslst:cands or dce'sLnai degrees:
(ifivell Geld.one lat/longissuffacicnt) r,_.,. ar',r l,;%7a;i!ft; J t/+{) ���vf� 11 I
22.u er h?LCIIt`eeII:
t1
6.Is(are)file wells)&ermsuent or RTewpora,y signature orCenifred Well Contract D e
By slgaing Ibis fares,I hereby eelfify that file 1re1IN irm(were)constructed fa accordance
7.lis this a repair to as esistiug well: Dares or L NO whit ISA(✓CAC 02C.0100 or ISA A101C 02C.0200(fell Caavtrrtcilatt Slmrdardv and that a
!Rails is a mp6ir,fill oat lalmr7l well construcilmr to formation and explain ilia uatare rfthe copy gr1his recordhas been prmAkd ro the well awner.
repair wider 921 retuarkvsection arms the back oftbicform
23.5ite diagram or additional well details:
S.For GeoprobeMPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only l GW=i is needed. Indicate TOTAL NUMBER ofwelis construction details. You may also attach additional pages if necessary.
drilled: Sl<IL'iL313'1•A L INSTRUCTIONS9.Total well depth below land surface: E2q5 (fL) 242. For All Wells. Submit this form within 30 days of completion of well
For multiple irdlsfst all dapUav ifdiferent(example.3@209'am12@I00) construction to the foliowing:
10.Statde wafter level below top ofeasing: `� (ft.) (Division of Water Resources,lnformation Processing lUnit, .
Ylvalar iced is above casing,use"+" 1617 Mall Service Center,ld 610,NC 27699-1617
11.Borehole diameter: _ (eD.) 24b.For infection Wells; In addition to sending the form to the address in 24a
11 Well construction method: ry ;f' above,also submit one copy of this form within 30 days of completion of well_
dry,cable,direct construction to.the following-
(Le.auger;rat push,etc_
Division of Water Resources,Underground Injection Control Yrograrn,
FOP.WATER SUPPLY T11 ONLY.- 1636 bEail Service Center,Raleigh,NC 276994636 •
I3a.Yield(gpm) 7 Ulethod of task: &ACYt_�-•TMe 24c.For Witter Supply&injection Wells.. In addition to sending the form to
the address(es) above, also submit one copy of this form y}Abin 30 days of
Ia'b.Disinfection type: 7�©`0 Amount: �CcOZ completion of well construction to the county health depmtntmt of the county
where constructed.
Pone GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised?'2016