GW1-2022-09985_Well Construction - GW1_20221104

WELL CbNSTRUCTIGN RECORD'(GW:1) For Internal Use op[
1.Well Contractor Information':
` 2 C / :IUWAE' Z0NFS'•auti i•�v 7.Sr'•:.fiti iYi`•�.NCi'P}+i uyk:�gfl.,..i�S7r:''t'YI•'.:.•:••.•Y:"• '.t.l..
Well Contmcto Name FROM• TOEj CRiPTLIN
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NC WellConhaetor Certif catioaNumber 515IOUTIIi QASING foiiaulNTvl'erell� OAZIIVER fe"'IIceble,�.tf?iiX�� :,'1r si
f 1 FROM TO DLVAMR TIUCKNESS 6!E►TERIAL
CompanyNamd' 2— i
•� C� 16II'IIQERCASING'OR'171B1NG:'eotltdinlelela`f&1�Ioo'?�C:t 'eylil�:z�'S?tWl,W
2.We]Construction Permit#: Gl 7 % FROM IM D110MMR. Tmc[a�ess I.MATERLAL
I.tstallappft=ble:veUeonrf cddnpemirts(LaUIG Coto*Stata•Yoriance.ete-) tt•
3.Well Use(checkwell use): ft. & da.
WaterSupp Well: =17.SGREEN "'c:7`�t ' a'ti��ii:3ttat<tx,pr',6:�a�i4ti r!; S?a " P.,e.; ,
PRO
h1 TO DIAh>ErER SLOTSI7E THIC[QVPSS MATEgIpL,
Ag►icultu 4 ' ' . 13.MuniciIM&,0Ga O , R
Geothermal(Heating/CoolingSupply) idential WaterSupply(single)
1.
Indush'idt4ommerciel EL ft In.
�ResIdentialWaterSuPPly(shared) �g`GBOUTltrSY'itEi 1^efi u n'S"���b�{S1 vYr�{ .•� ry1 f,.�ry
1A�I44: _f7H~i Wiw �te�•./M'��:D•iL'{,`llf.''.'a J'i,,:J:l'tJ'R:l�n�
hri lion FROM• TO MA EMPLACUdMVMERiOD&AMOUNT
Non-Water Supply Well: R IL
Monitoring, DRecovery R iG
Injection Well:
AquiferRecharge DGreundwaterRemediation
fs19:SAFIDlGRAVEIrPAGK 'a''"lte6ble�"•' ri?3tic::w,f!•Y.•ai keaas s'�3u? b�wL7: i trifer Storage and Recovety ElSal'in'riyBanrIer FaoM• ToI brATEML. mu►reLl+co=h>Ettra�reoa
_AquifetTe� j3StorrwaterDminago
ExperimenlTechnology QSubsidenceControl !e to
Geothemm (Closed Loop): Tracer v2o 6i[iiexe+s' '4;1• i t,;'.t� ; ;.:
'DRIf:L)NGI.OG ®hiseLadditifiiud�hea ''G+;E"•. �:•,! z
Geodie (HeafmrMooling'Retum) Other( lainunder#21Rcmarlcs) FROM TO D1 Cmt>QiiON eatoRrunteeu,satvmek ,ma,ew
ft. C ft. ,,
4.Date W s)Completed. `L ZWell M# ej IL , m s r0 nin 5 C.(
��Oa.WeIiLocafton: p Zr •' h •� .
JFY>I rt4P
Fd/cl lW/Owner ameN V p r :c jO a FaeihV MR(tEeppRoble) ft
�/_/ �.5��'S L:'� f1 P �-h7Ey' ���L;�jj•e Jar Cf
PkWMAddwi%City,ohdZip ,� (t:? ft. ft. V U -'
MU PMWAPM r,:;F: <e�::.1 n2i b• 3:t.�t lwenrr ti4i'.i4'nic•i't}Ih°�4 ,ui'M'.•r2o I:Sti� "•�
r...plii" ' 't•�
Comfy xafc4l entffiwHgnm.(?" 111/v+ 1Rt�i 3�
56.Latitudelaad longitude in degrees/minutes/seconds or,decimal degrees:
(ifwcUfield.o latilongiasa� Acient) r '•' ,t 22.Cettifieatioa:
6)Y �lr�J� W
6.Is(are)tb�:weII(s) rnmanent orTemporary' sigotfteorcaffiredwouconhuctor Data,,
y fiprnS ftjh.+4 Jhereby'een{Jy 06t1 fhe m'Ws)inns(tver41 consaacted In ap:ordanee
I L this a repair to an existing well: Dyes or EINo' mvlth ISANCACOIC.D1o0 or ISAWAC,o1C.020D fYell ConrhaeflonStmrdardtandfhat R
Ijthfstsarepatr.J7UorrtlaWmvnweUeomrstruettonfitformattonaad4rpkht the nafrrregjehe copy ajehlsmordhatbemptovidedm the vamrhw.
repafrrmder#2lreraarlamNonoronthebaekojtlrrsjorm. i ', r
23.Site diagram or additior4d well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Welts having the same' You may use the back of this page to provide additfoiW well sits details or well
construction,only1OW-lfs needed.lndicate TOTAL NUMBERofwells construcCwndeter7,s..Yon''mayalsoat6chadditWnelpagesifnecesM
drilled: SUBMITPAt,INSTRUCYIONs
9.Totalwell depth belowlands*ace:•• �s' (ft.) J
Z48.For All Wens; .Submit this fonn'wAthur 30 days•of completion of"
Formaltlpiemlls/[meal!deplhsfjd(�aent(exmnp1�3Q100•and1Qa100� cousbictiontothefollow4ng: i •; .
30.51taticW terlevel below to ofeasin •-
P g• 4� M. DlvisloaofWatecResourcee InformationProcessin Uri
Ijwarerlevei abWcearin&use+" 1617MaI1SerAccCeuter,Raleipim,NCZ7699-16�7
11.Borehol diameter: (in) 24b.For Infection'Wells: ht addltion!to sending the film to the address in 24a
IL Well construction method: �® �/�!`y above,also submit one copy of this Ibrai within 30 days of completion:ot�well
Cie.auMzot y.-ble.diceetpus%etc.)
construction to the following: I
Division•ofWaterResources,'Uidle rommdInjectloaControlPrograrn,
FOR WATER SUPPLY WELLS ONLY: 1636Maf1Service Cc d r,Raleigh,NC 2769X1636
13a.Yield(drum) 20. Method eftest: •'/ + 7 24c.For Water Suaniv&Intecti n Welts: In addition to sending-the form to
the address(es) above, also,submit°oho'copy of this form,within 30 days'of
13b.Disinfection type:t2 :r,t� Amormtz_':�t l Gt o completion
d.o cte construction to a County heap$ileparmaent of the eouaty
hpl
. it ' . •4 j .