GW1-2022-06481_Well Construction - GW1_20220706

r
Print Form
WELL,CONSTRUCTION RECORD(C'VV-1) For Internal Use Only:
1.Well Contractor tnfornialion:
/�n;
_-
4i+ll,Vtl�,v.�j"B:"J( .a !.".5.4-64 ))Fri 1a.WATER G
Y ---�-- —
- Well C'onn'ataur N;um ll`T14N
t
/ •tl l07 fl. I'U fl. GE1C� t^ d r L ti.� •y'"�. t�
. . / S
ft �� fL ._._... _..._ ...._............
NC 1v"ell<'nnuncux('crliticanun Number -
(_-f-t-,. A'STNC (for
fl,
Itl-cas l ell wells)
)OR1'ILINER
E.vti(_.Ii'f a_
I_fcA.a-IAb.l.fe-C)
UTq•'?
Company Nrmc 16.INNiR 1ti1NC OR Tt iBLN(, `eothermat clused-too)2.sWell Construction Permit#: (r G�/) N fU nL\UV T11 rlu(KNE7 fnT Rf_t 1A:l ...__— -
lil _
...---.._.._`..-
—id/uprlicah/r nr1/o"'Istru,.lira,rrrntils ii.r.(, C("wunti,Vale.l'oorirn ce.r,r.) ft. fl.
3.Well lase(check well use): i-ft.
Water Supply\hell; - 17.SCRIs15V
I ItU19 'YO- UTA�I I•"hr,lt Slw'r sue. 1,111C MA•fGltl NESS _11..
A);r,euhu,'sil DMuniell);, Public ft. -
Gcother7mal(lfeating Cooling'Supply) DRcsideniiul Waici Supply(single) ---
tr. (t. in.
Industrial/C'onnnerc'i;d DResidential Walea Supply(:;hared) ---- ........
IN.CROU'r
11'i'Igatllln __ ruon/ it) __ 1tA7T.ttfnt. EMPLACEMENT NT M1_;1 OD&Am>f(UNI
Non-Water Supply Well: W ft — -- ft. - — - -'
- -- ----- -�Rccovc:ry' --=---................----..._.......___— -----
tvlanilorilat� n. ft.
ff. ft.
IAquitcr Recharge Ciroundw;atcr Remedi;ulltn
19.SANDAMAVI?l,P.A(.:K(if a audictable)-
Ac)uil'nrStor:rgcandRccoccry- D salinity Barrier FROM 7u MA I'FR1nr I•:11PI.\('f•:111•:N1'A7(7ll(n>
Atoiler Test DSlor water Drainage
}i;.�perinlenial'fe.clrilok,gy' ©ISubsidenceComm] t). ft.
Geothermal(Closed Loop) fraee' 20.DRILIJNG LOG attach additional sheets if necessary _-
_ .. FROM ft. rrt) u rs(t "ruaN(color.bard"'.",soVrnekGeotherulal Meat lcspOther lain under t;21 Remark:) 1ed '7J 44,.AA
t�e�rnin sire_etr._
a w/1 cif I r
4.Date Well(s)C'onapleted -'�r Well ID1t `7
_._ 11 I J S b'r�; ,sly t5'd�.+rr .✓� R�.• _//� .
na.'Well Location: S 5 fl.
P�nt•ilitt't.)tvnrrti;unt• f;u'ilily II),llil:y,plirablc) -(t.-i LL ft.
Il. fl.
Phytaa:al Addres..(ity.and Zip ft. - ft.
W,_f t s.✓t./ 21.REMARKS t------._._.-----"-'--.__ --_'—
Comm' _ --- Paicelldo111ficationN.,.(PIN) ��M. e^I`c.✓' /W(� �� ,j� ry�Ot�+� �/- rf`4•�i, d�1�„✓��
51).Latitude and Iongilude in degrees/minutes/seconds or decimal degrlxs
ollvell field.mic lat;Iong is sufiiclenl) y+ )2.Ce1'Iitication: •�re,,:yo'I a �..' �11 a
_
6.ls(are)the well(s)o1permanent ul, Da J T'emporary Sicnalurc o(C'crtified ld all(.'onln,ctnr hale
Nr signing dui.,Jnrul. /!a•rr/n•rrriifi'thin the wrliAl urn..In'rrrl,:nusrrurr,'ci u,un art/unrr
7.Is this a repair to in existing well: Yes or MNo trirh I s.1,y(':df'Ur't'.r1U0 ar 1 t.)A('a('02C.n2n elu l/Coimirnrriun.Sunul:u'da'and r)au
//Ihis i.c a r<./ruG'.fill art kunu'r ux/1 cwt,trucrion iq/nrmuuan and ci phim Me nature illdrr rorr ul'ihis i rii,rd has been prm-ided to the drr!!uo'ner.
repair under ri.'1''rnmrA .,rr all or nil rhr'hill h n(dri.s
23.Site diagram or additional well details:
X.For Geoprohe/DPT or Closed-Loop Geothermal Wells having the Saute You lnay use the buck of this page to provide additional well site details ill .+ell
construction,only I G w-1 1,,nceded. Indicate 1'OTA1.NI I<4BFN ol'wolls Consuuctron details. You nlav also'atlach additional pages if necessary.
drilled:
Sl1RM111'1'"fell..INSTRUCTIONS tONti r �� P,t
9.Total well depth below land surface: _ (ft. 5
n/r/up1,•t,• /„ !' /,' I ) 24;a. par All \Molls: Subnul thry limn wi f un l days of I:omplcmoll ill'd.rell
llv. 't„/I/lr!/,t r of rule./r.inn r/r silo_'llr',rnrl.�'.l-/ill!') t:tnlsn"lictntn to fhc folhtwing:
lU.Static water level below tap(if JUL 0 3 2022f eosin(: "� - (ft.) Division of Water u'r Resources,Information Processing Unit,
d',;rr: t,anotr rn,rnp;.tr,c ' 1617 Mail Service Center,I yr�t) f<; Ttl # � Unf
11.Borehole diameter: C (in.) f P\NRfP6
24h. For Injection \Melts: lit addition to sending Lh. fiG'i o tc address in_4a
V above, also stihmit one copy of this 17mn within +O days of compleiion of%will
12.Well construction method: Coll.II'mIion to the iollownw:
t,.c.autper.nnnry,cable.dyer!pusb,cues) �
-- Division of N%aler Resources,I.riderground injection C•ontral Program.
FOR WATER SUPPLY WELLS ONLY: 1636!Hail Service Center.Raleigh,NC 27699-1636
13a.Yield(1;pill) - „-„ Method of test: �- 24c. For Water Sunnly & Iniectilm Wells: In addition to gentling,the form to
the adchras(es) above, also submit one copy of this form lcithin 30 day. of
131).Disinfection hype: Amount: completion ill well construction too the county health department of the Comity'
-- _------ whera constructed.
Form i i1.V I Nrnth t':n'olinn I w I m Iromuicntal t)turlil. .D1\rum