GW1-2022-06992_Well Construction - GW1_20220725

Print Form
WELL CONSTRUCTION RECORD (GW-1) For inl(rnal Usc Only:
1.Well Contractor Information: / R�
A( 1 i �j ? r / 1•' �I M ED 1.,WATER ZONES
Well C:onliaccllor-Name /'� n F12UJ1 .1'0 nl::s(,w11TIU\ .
t / 6 /4 JULJ1 L G
NC NVell Contractor Cerlificalion Number �l"P*2 41 UQC i`�l�(J,' tes� �c e7
"00 15.OUTER CASING(for multi-cased%sells)OR LINER(if ap able}
�t 4 Pltll�l IY) DIAMCAT:R 'THICKNESS �I:YfFRITI.
5 C cam.4:� � l),-,/,�,_z,�.r %
ft. R•
Company Namc -' J in.
16.INNER CASINC OR TUBING(•euthermal dosed-I0o
2.Well Constriletion Permit#: w2om , to DIANIy'2'r•:R THICKNESS MATFRIM.
Lis(u!!goplirrrhlr,rr•ll cun.cm,chn,r pctnrits I"'. U1C',('nturm.Sarni•. I';1111ML•,clr 1 fl,
3.Well Use(check%sell use):
W
ater Supply\Yell: 17.SCREEN
PROM TO DIAMETER SLOTSIZE TIIICKNESS 31ATT:RIAL
cultural \'ltn)icipal/Public
hennal(Ile:uing%C'ooling Supply') aResidemial Water Supply(single) i
fl. ft. in.
strial/C'ouirnercial Residential Watu'Supply(shared)
i8.GROUT
tion FROM To UATEItI:\I. l:?11'1.:\CICDIEKT mm-11OD AMOUNT
Non-Water Supply Well: n-
itoting �Recnvuv- -- fl,
on Nell:
ft. ft.
fer Recharge E]Groundwaicr Rei ediation
19.SAND/GRAVEL PACK(ifa %licable)
fer Storage and Recovery Q'Saliniry Barrier FROM To vMTPI1IAI. t:atrinct:�teN r Nwritoi)
ifer Test DSlonnwmterDrainagerimental Technology DSubsidence Controlhemial(Closed Loop) DTciccr 211.DRILLING LOG(attach addilional sheets if neemarv)
Geothermal(I leating/Cooling Return) Other(explain under 421 Reniarks) MOM
{`� � S-To Descun''I'lON(M.".hanlncss,soil rock n re Bruin sin•,ctc.i
fI. ft-
!
j'
4.Date Well(s)Completed: Z \Yell I D# VA I I- C,f � r) rt. 3 S h.
J1 i
5a.Well Location: -j ft. v
ll� �/- JLUj!��S Gj}1 ft. ft. ,G
% r6,I' c J_
FacdimOwner Name Facitiq•IDrt(it applicable) If. ft. v n.
_0 G�1 1. IIfs /! �� �` fl. �, fl. t^L?,.,,���lrt( OC
AC
36'0 L��Ci✓fir
Physical Address,City.and Zip C r i P;trS/) J, i�' ft. ft.
21.RE%IARKS �L J j
County Parcol Identification No.(PIN) �C= ���+"olry �J1L' Q��%nhCL+v2, e rY�-Si'a.�Jf �•j\-y
5b.Latitude and longitude in degrees/minutes/seconds or(decimal degrees: "r ri L. +ti�.�.r ►J+ t"e nt, t� >�ro r•� I L
lif%%-ell field.onclat:longissuficienti 22.Certification; %.75�•ri�wC � ,i>. /'.w✓ i- i� '`_��
36, 06o92
6.Is(are)the%%'ell(s)OPernianenl of- 01remporary Iullaturc of Cerlitied Well Contractor Date
Br sitnha,:this pave,I bushy ccrtili`rho Ike u11l16i n,L, nrerei'.nm'bmct.-d M accardaner
7.Is this a repair to an existing%roll: O'Yes or DNo aids 15A NCAC 0J(-Alai,n:-l.i,I.v('AC'f)2C'.020/,11'r/1 C'rrnea�urrio,r Srmulmj,,,nd char a
lith'c is a ripah.fill wa knn,nr ur!!ro,asn'urtiun rnlurur,ttiun and r.rpJi,in the naim i,nJ tin, cnpr #this...curd hue barn prnrided ro r4e well rmrn.,.
"'J'ah meat•.n21 re'lark'section„r on the hark"Ohl,Jinn.
23.Site dingrain or additional well details:
S.For Geoprohc/DPT or Closed-Loop Geothermal Wells having the Sa1110 You may use file back of this page to provide additional well site details or well
construction,only I GW-I is needed. Indicate'FOTAL NU\gB6R of wells construction details. You play also attach additional pages it necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: � (ft•) 24a. For :UI Wells: SLlbmlll this form within 30 days of completion or well
I'm-mrdriple,rrl(r list all d,Into,it dill;.;, / and_'!cc 1101 .
construction to the liilluwing:
10.Static water level below top of casing;
1l,runv kw/i.,nh
(ft.) Division of Resources.
Water Resoces,Information Processing Unit,
o,•c rust,{e.,r." "�" ft. 1617 Mail Service Center Raleigh.NC 27699-1617
11.Borehole diameter: �7 (in.) tab. For Injection \Yells: In addition to sending the limn to the address in 24a
12.Well construction method: Gay'.(✓ above.also submit one copy of this Iiirm within 30 days of completion of well
construction to the following:
(i.e.auger.anon.cahlc.Jircct push,Beal '
Uivision of\Pater Resources,Underground Injection Control Program,
FOR 11':\TE12 SLiPPL\'WELLS ON1,1': 1636 IN-tail Service Center.Raleigh,NC 27699-1636
13:t.\'icl(i(tipm) {Method of test: 24c. For Water Supply& Injection Wells: In addition to scndine the lbmi to
the address(esl above, also submit one copy of this form within 30 days of
131).Disinfection type: Amount: completion of well constntctiomi to the county health department of the county
where Constnlced.
Form('i1Y-i Nnnh Carolina Department of 6ncironna•lual Ouafily-Di:isioa of\1:ucr Rcsourccs Re\iscd 2.22-201 L