GW1-2022-08734_Well Construction - GW1_20220826

WFLL CONSTRUCTION RECORD(GW-II For Internal Use Only:
1.Well Contractor Information: _
t4.WATER MNE4
FROM I TO I DEscltueTlolu
1Vell Contractor hmne
70v 32b ?A0-)
NC 1Vell Coutradw Cetti£catim Number 13.OtTFER CASING(bbrmuldrimsed wells)ORLINER(tra ubbte)
FROI,t TO DIAMETER TMCRN M MATEM
���v` �S I ��C U ft. -1 d ft. in. s u i l O VE
Company Name 16.INNER CASING OR FIIBING(eothermal closed-loo )
2.Well Construction Permit ff: :P®a O d 63 Z3 FRaat I To I DIAt1 EM I IMCKNLRs UTBRI AL
Litt all applicable hell construction permits(i e.UIC,Coa2uy.State,Parlance,ere.) ® 8, tt. , Z rtn s t z I P VC-0
3.Well Use(check well use): O' R'
Water Supply Well: 11.SCREEN
Pp FROM I TO I DtMfETER I SLOTSIZB I THIC[MUS I MATERIAL
Agricultural []MuaicipaMblic
Geothermal(Heating/Cooling Supply) Woesidential Watcr Supply(single)
IndustrtaUCommerciat 13Residcntial Water Supply(shared) 1>l.GROUT
If i 8tion FROM TO MATERUL ENjmAcmLNrl%wmOD&Akio TT
Non-Water Supply Well; v a. ft.
r
_. Monitoring DRecovery tt. ft. �%
IDjection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAiHQIGRAVIIrPAC$ applicable
AquiferStoragc and Recovery 0salinity Barrier FRO]t To MATSRI:u. I ENtlzACIMMNTMEMOD
Aquifer Test 0StormwatcrDrainage ft. ft.
Experimental Technology DSubsidence Control
_ Gcothermal(ClosedLoop) OTracer 26.D MING
Geothermal(Heatin lCoolin Return) ar Oth (ex Iaiaunder#21Remarks) FRG' To D�cttleTlote(oilnr,bardae�sotutnctc e. alnsiaetr)
ft. ft. Coles. ®w.VbLky
4.Date.Well(s)Completed: 9-1%' M Well IDS ,.
So.Well Locations ft. R'
�'1
racilitytOwuer Noma t q � Facility lDE(jfapplicable) _ _= J
o WEB - Q by\d t te(oc It v?
Physical Address,City,and Zip
taV1t°60—ne' 31 CA I LtZSI 2(f ZI.REMARKS
County Parcel Identifiication No.(Plhv
Sb.Latitude and longitude in degreesiminuteslseconds or decimal degrees:
[if well field,one ladlong is sufficient) 22.Certification:
3 5°35' G- GY3o "N ggZ® yz ' S7. 4�.s5
Ms(are)the well(s)Vernr►anent or Temporary i Signature ofCertifted woU Contractor Date
By slbiting ehisfornt,r hereby crrrify that the nell(s)ivas(icere)constructed in accordance
7.Is this a repair to an existing well: 12Yes or O iv*h ISANCAC 02C.0100 or ISANCAC 02C.02001Vc11 Carutracrion Standards and that a
Ifdds if a repairs fill out luioistii ivell construction informatlon and explain the nature of the copy of this record has been proul led to the well otrner.
repair under 021 remarks section or on.1he back-of thisforin. 23.Site diagram or additional well details:
8.For Geoprobell)PT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
rnaauuction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells
constiuction derails.You may also attach additional pages ifaocosaory.
drilled: CiMlbTrrTeit_iNs7CRUC Tk
9.Total well depth below land surface: L/A M) 24a,For All Wells: Submit this form within 30 days of completion of well
For muh(pte hells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
If eater level is above casing,use"}" 1617 Mail Serviee.Center,Raleigh,NC 27699-1617
11.Borehole diameter. 41. ML) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: h�i.�I — construction to the following:
(i.e.auger.rotary,cabie,dircct push,tic.)
Division of Water Resources,Underground Ituecdon Control Program,
FOR WATTR SUPPLY WELLS ONLY: 1636 Mail Sevlm Center,Raleigh,NC 27699.1636
13a.Yield(gpm) Method of test: A- n691e 24c.For Water SMilly&Iajixtion Wells: In addition to sending the form to
the addless(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: �O<'% Amount~ 4 completion of well construction to the county health department of the county
where constructed.