GW1-2022-06156_Well Construction - GW1_20220623

WELL CONSTRUCTION RECORD Forintemal Use ONLY.
This form can be used for single or multiple wells
1.Well contractor Information: ; —WATER ZONES
T�� t/�t�-�"r FROM TO DLIPT[ON
Wei I Contmcwr Name
tt a i h( Cad.(S;
a- +1
/�1 C�d 1 C , 3�._.__.. ;g,O(JTCASIN43 oriel i•can d ivrlte OR LINER it a IEcable
NC Well Contractor Certification Number FROM To OiAb1Ei ER
TRiC[aVES3 MATERIAL.
0 ft' 8('� fi' ,rZB ln. �}.�>• PIPI;
Company Name Ili.INNER CASINtx'ORF TUDINU tothermaf eiosed3
? a FROM TO DlM1EfER T11rCKNE58 MATERIAL
2.Well Construction Permit#:_ s7 3 ( it.
Lis!all applicable well pem;its(i.e.Colwy,bYate,Vm imrce,lllftd an,etc-)
3.Well Use(check well use): th•`S
OM TO II tETER QATSM TirtCKNEM MATE1h1AL
Water Supply Wen: C� ft . )!I
QV
OAgricultumi OMunicipai/Public (7 R fA �
00cothermal(Heating/Cooling Supply) ocsidentiai Water Supply 0-1161e)
FROM
GRQUT
Olndustrisl/Commercial oResidentiallllater Supply(shamd) [ROM TO MATERIAL EMPLACEMPNrMEfnOII&AMOttNr
❑irti ion p ft
Nos-Water Supply Well: fw Ik
OMonitoring r� ` ft ft.
injection well:
❑Aquifer Recharge I ��dwater Remedietion J014
I-�TEI P6C[C a AL
1V TO AIA7EltrAL fiMPWCEMIiNT11iEfHOD
OAquifer Storage and Recav .r ity$airier ;is I to rs. �-� Cn�vu- �u e�D
aAquiferlestR,r0ggLov {il?rainAga Ol;xperimerttalTechnol � ,�jBoObsidence Contra] 0;LOG Bch sdd[tto-I sheet ifneceaCreothermai(Closed Loop) OTracet To osscRuYrroN colorE30eothcrmal Heatin Coolie Return) t70ther sin under 421 Remarks12 a,
4.Date Wells)Completed:�Weuw# 9 t
58.Weft Location: p R' n �C
n Facility/Owner Name Fecilityll]#Vapplicsble) Go O. 716
{t
r r o
Physical Address,City,and Zip Ne - 2LREhlAR1G5
County Parcel ydeatifieationNo.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certificolion:
(ifweil field,one lamong is sufficient)
• �e.._. `7�� '���}fy w
Signature ofCcrafied Wall Contractor Datm
6.Is(are)the weII(s): ermanent or OTemporary By srgatag this form,1 hereby Certify that the wel!(sJ it=(were)oonstrueted in acoord—
ivlrit 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Constrttelft Rw dards and dial a
7.Is this a repay to an existing well: OYes or ONO Copyofdds record has beenprmdded to the well msnen
tfws is a repair;f ll our known wellGonstructtotr i,&wtatian and explaln the nature of the 23.Site diagram or additional Well details
repair under 421 remarks section or a:the backofdriafbrm. You may use the back of this page to provide additiOrAl Well Site details or well
1 construction details. You may also attach additional pages if necessary.
&Number of vvetls constructed: .
For multiple IVcctlon or non.water suPPlyweUs ONLY with the aante eortstnrctiorx yott can SU$ AL iNSTUCTIQNS
submit oneform.
9.Total well depth below land surface: /1 ((L) 249.jior 11 ells: Submit this fa m withili 3D days of completion of well
Formuldphs wells list all depdas(fdtpnw(xample-3Q200'and-7@1007 construction to the foilowin .,
g•. / (fk) Division of Water Resotrrce%InibrDlati
LQ.Static water level below top of casin on Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
lfrraterlevelOabmecaslrtg,or"+" .
11.Borehole diameter. or tt (ia.) 24b.)Fgriniectlen Walla ONLY! In addition to sending the form to the address
24a above,also submit it copy of this form within 34 days of completion of v
12.Well construction method- V cocoon fonowing:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Reuources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,ITC 27699-1636
FOR WATER SUPPLY WELLS ONLY: C
24c.For Water SuDDly&i4lection WeI1s:
13a.Yield m 3U Paw Methodoflat'.
(gp ) � Q � Also submit one copy of this form within 30 days of completion of
e-Ac-c 1 u P^ �19P ckcoe,Y 0-Amonni /G wall construction to the egiuity health department of the county where
131t.Disinfection type: constructed.
Fort GW-1 North Carolina Department of E11*omllent and Natural Resources-Division of Water Resources Revised August 2O1: