GW1-2022-07658_Well Construction - GW1_20220818

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WELL CONSTRUCTION RECORD(GW-1) For htlemal Use Only:
I.Well contractor Information:
fv r�h�llrYJ�/ 14.WATER ZONES
FRt1\I '1'U 0F.Sclop"!lON
Well(untracaa Name L^) S`fit. G, oiff'tV'Wft fire
14 ft.
Sr .- flit 6" 14� c-
N('WeflContractorCerlification Numher 15.OUTER CASING: for multi-cased well. OR LINER Ifa licable)
FROM 1 DIANMFR 1'lll('KNF:SS NIATERIM.
�/r fl. ft. in.
Company Name _ j M INNER CASING OR TUBING, mothermal clmed-lou
���I�U✓C I+R(IM 1'n 21ASIFTER TRICKNESS MATERLU,
2.Well Construction Permit fl: a. ft. in•
last all aPl,lirnhL yell cun5trurtimt txarmt,ti.r•.G IC Cnnntt•..S'!nh•.C,Airnlre,cunt
n, fL In•
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM 1, TO DI:\MF.TER SLOTSf Z.E THICKNESS NIAl'ERIAL
Agriculmml QMunicipal/Public ft. ft. in•
Geothermal(I lealing!Cooling supply) oResidential Water Supply(single) fit. fit. in.
IndustriaUCununercial OResidential Water Supply(shared) IS.GROUT
ICPI ration r•mim- C FROMl'q MArF;Hh\L I:DIPL:\IT:MF:\T p1ET11011&AMOI;NT
fit. ft.
Non-Water Supply Well: N 5 --
,Monitoring Recovery• tt. ft.
Injection Well: AUG 1 fl. B.
Aquifer Recharge aGrnund\vatcr Remcdiation 19.tiAND/('RAVF,L PACK({f a licable)
A((aif'er Storagannd Recovery I yt�t)31}ahtnric�^^-11;,= ': �U � FROM TO MATERIALF:\FI't.ACE.M::\'r\1F,TIFOD
lonni;Qii1rt��1TiTfg
Ayuifcr Test 0�-
S
Experimental"rechoology Subsidence Control ft. ft.
Gcothential(Closed Loop) 01racer 21).DRILLING LOG anec11 additional sheets if neressan•
FR/Ill To DESCRIPTION Icalnr.hardness,sniernck is e, min site.cle.l
Cicothennal(ileating/Ci cling Return) Other(explain under t121 Remarks) i O 1. !-L n. L <, -a• I,,4.Date Well(s)Completed: 7- Z Z YYell I Dtl5/7 f)'133 Z fit- 3 o ft. r i Ja r c
{a.Well location: _
U ft. ft. c/!•1{ te
n. ft. - M
Iaofili;owncr\;unc Facilily IDd(tl applicable) ._
(I. ft.
ft. fit.
Physmal Address.Guy'-and Zip
so 21.REMARKS
m r PC /l/f c'l r^�'
(:arty Pan:cl ldcntilication No.t l'INI c ' -C �/ ,[ �r ( J
YIL\'t� n,,
Sh.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ��� �, N u 6_r :
ul well field,!me lar lonp is suflicicnt1 22.Cer(ificali": ' '�; ' ry�� -
Signatia'c ol'Ccnilied Well Contractor Date
h.Nare)the wellWoriermanent or 0•remporary
Hr s,gnink This(non. I ronso"'trd:n mere.hp-.
7.Is this a repair to an existing\\'ell' Dyes or MNo r 1h UAW* lu(".n1nn n, 15d AVAC n1C n?nn a r-l1 Cn 1,10 wilnn sea"da"A and Ihrr a
1t dna a rt rcpaur.fill wa knmo,.cell<nnatrnruon inlnrnmtmn rout,a'jrhtm rhr nann'r q1,hu. r'nln•u(tht,rernrr!has brrn lnnrided w the+cc•11 ur+'nrr
repan urah•r a_'l rvtnavks,vrnor,nr nn the Ira,6 ni,his lnrn 23.Site diagram or additional\\'ell details:
S.For GettprohelDPT or Closed-Loop Geothermal Wells having the same You lnav use the hack of this page to provide additional cell site details or well
construct,(),,,uldv I(iW-I is needed. hlciicate TOTAL NUMHIAZ of wells
ronsuuction details. You ntay also atiach additional pages if necessary.
(billed: SUBMITTAL INSTRUCTION'S
9.Total well depth below land surface: G'� Iff.l 24a. orconstruction All
Wells:dlu Submit this fimt'm withirm 30 (lays of completion of well
1'+n nudriplr n 41,li't all dr»hc d dillr•n nt room/Jr-.Fin_011 wul]�a lt1l1'1
10.Static seater level below top of casing: (ft.) Division of Water Resources,Information Processing Unit.
h mnr•r k•:v7 t,ahnsr rsi„1:.,rse 1617 Mail Service Center.Raleigh,NC 27699-1617
I
11.Borehole diameter: E7 (in.) 241). For Inieclion Wells: In addition to sending the li)nn to the address in 24a
above.also submit one copy of this form tvithin 30 days of coniplenon of well
12.Well construction method: SC?Al, L. construction to the following: i
ox.auger-imary.cable.direct pudt.rtc.l 1' ,
Division of Water Resources,Underground Injection Control Proiram.
I'OR WATER SUPPLY WELLS ONIA': 1636 Mail Service Ce I nter.Raleigh.NC 27699-1636
13a.field(gpm) Method of test: 24c.For Water Supply C Intectiun Wells: In addition to sending the fhnn to
the address(cs) above. also submit one copy of this form within :0 days of
13h.Disinfection hype: Amount: completion of well construction lolthe county health depanmern of the county
where constructed.
Form tiW I North t'arolina Department of hm ironniental Clualn%-Ili+iaoti n(N'atcr Resources Rcsi�cJ_-2'_-21t{t.