GW1-2022-07662_Well Construction - GW1_20220818

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information::
f IJII�/'v(1) /Tji:l C QSCGJXt� uC��/re'� MVC
4. Dlscaurrumwell C`enaacloi Nan)cft. lGGC;. tjifle
CWdl C'ontnctnr Cenilicauon Number or multi-cased wells)OR 1.1NEvableDh\\IIiTt:R xL1l't:RIU.
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i'ontp;nn'Name /t ��t11 ///� 16.INNER C!77-
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Tl11CKNESS �HATERIAL
2.Well Construction Permit#: C L / ti : - p•(i.'i•.U/C'Corrnp'.Sfnlr. Inrmnnt ew)
3.Well rise(check well use):
17.SCREEN
itterSupply We[l: roue% rO DIAMETER SLOT strE TntCKN6s MATERIAL.
^Municipal/1'uhlic ft. ft. in.
Agriculnual Q .
C,ieolhcrmal(I IcatingiCnoling Suppiv) Qll;esidential Water Suppiy(single) ❑, 0, in.
In(IustriallContnterci:li si( n b) to �pg�iphared) IR.GROAT
y i FROM To ntA1111,u. rstrt.na:ntE�Tarr:Tuonx.naaiuN'r
Irri'anon a
ft. 0.
lion-Water Supply V1'ell: 2Q22
• U ft. ft. .
Monitoring qve y
Injection Well: I'r ft. fr.
Aquifer Recharyc nod +list:f rot'�ti(i�itMi"
q t11{ ( ?thy(, 19.SAND/GRAVEL PACK(if applicable)
AyuiterStora¢c and Recovery Sal(ir1� 13 111vK FROM ru %tnrsRtnh Faml.,\CENIENr str:Tnun
ft, ft.
Aquifer Test OStunmvater Drainage _
Espeiimemal Technology DSubsidence C'onuol fl. ft.
Ge0lhemtal(Closed Loop) Tearer 20.DRILLING I,OG attach additional sheets if necessary
FROM l'1) Df:SCRIP'1'ION kolnr,heMnrs.cn+Urn<k t% r, rein aim,etc.
Geothermal(Beating/Coolin r Return) Mother(explain under 1121 Remarks) r rncvti/ ` sal e�_
4"Date Well(st Completed: 72 Z` Z Z—Well ID# ��� — P rt' L h, �e /�ro(.v�•SLs -r fa ­/
L ft. O I.
5a"Well Location: c✓�
L ft. SS" ft. iO A. ar rI
rl, rt.
I'acdilv4hvner Nufm// `. Facility ID+t til aPplicahlel
o
lllivcical Atldtes�.C'ily.and ZIP
MRE�,NIARKS
1C �)�✓iCjO�GCoumy Parcel Identification No.IPIN) 4 ✓ Vrfen)Sh.Latitude and longitude in deg,reeslminuteslseconds or decihtal degrees: e�� u ��P 's41:well field.one lat'lolig is SlIictem) . �j Prof
Signnmre of Ccnified Nell t.nntractor i - Date
6.Is(are)the well(s)OIPermanent or [giTenrporary
ltr u.Rninl,rho/urrrr,l hr,chi r u n/r rhal 0, %111,u r ell r r+l rnmtnu wd m arurrr"m u
7.Is this a repair to an existing,well: [3l'es or No wdr/s.l,\( t('02(".olnu w l s I�(•IG'n C 0200 Ir ll 1 nrsu r rrr,n 5rmu1✓r'+11 rind don<r
ll;hi..i�a r,-p;rir,r//nrvt%noun ar/!i'urr.lrm Burr inRrrrnnriun rind dnin der nature ul the
ruin•n/ihis I., I ha,h+•rn pan,l+J m i!n•n,!1,,nrr.
rrpaw m der y21 remu4s -Prrm1 ur tin rh:hunk o%thl'h,rm. 23.Site diagram or additional well details:
You may rise the back of this paec�to provide additional well site details or%Veil
S.For Gcoprohe/DPT or Closed-Loop Geothermal Wells having the same construction details. You m:q•also ituaih additional pages if necessary.
construction.only I GW-I is needed. Indicate TOTAL NUMBER of wells
(lolled: _.-- ` St,111M1TTAL INSTRUCTIONS '
9.'1'mal well depth below land surface: SJ (ft-) 24a. For All Wells: Submit this t6rm within 30 days of completion or well
/'ur our/rgrlr❑vll,lisl ait d"I'll),d di/)error ,;vamph• 70.100.unr/J'u Mff) construction to the following:
I
10.Static water level below top of casing: �� (ft.) Division of Water Resources.Information Processing Unit.
11"arve rr del 1,'11 r,moire,%:.ter"r 1617 flail Service(:'enter,Raleigh.NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Yells: In addition to sending the Ruwt to the address in 24a
��N�•C above,also submit one copy of this firm within 30 days of completion of well
12.Well construction method: construction to the followine:
i re auger,rotary,cable.direct Pugh,etc.)
Division of Water Resources.(inderg;rnund Injection Comtrol Program.
FOR WATER SUF'PIa'WF:I.IS ON1.1': 1636 Mail Service Center.Raleigh.NC:27699-1636
t3a.Yield(gpm) Method of test: 24c.For Witter Supply& Iniection Wells: ht addition to scndu%e the form to
the address(es) above. also submit one copy of this form within 30 day; of
13h.Disinfection hype: Amount: completion of well construction to the county health department of the count%
where constructed.
Re,ncd -72.20I0•
F,nnt 6W-I North Carolina Dcpartnicni of 1_miromnemal Qmllm-DI,%sum of\1';ncr 1(csourag