GW1-2022-10369_Well Construction - GW1_20221115

WELL CONSTRUCTION RECORD For ttacnml Use ONLY:
This form can be used far single or mWtipk wells
1.Will Contractor Information:
14AVA HRZONtS
Zach Thompson FROM TO uFSCBIPr1ON
%viekorilmoorName
4478A fL 1L
NC Wcll Cor=IarCcrtifWionNumbei tS.OUfER CAsS1NG(r6ri-niiht casrd'Rillsti OR-LINER(if.-d flcable
FRONT TO pE�34F,TGR TrITCKNESS NTAT1 RTAL
SAEDACCO Inc 0 fL 34 IL 1 6" tn. Schedule OStainless Ste
e
Caa}p:utl Nanr t6. N%TR'CASING.OR TUBING' poil►ermal-laced-loa
FRONT T4 OL"IETLR TuierNESS hrATERUL
2.Well Construction Permit#: R. ft, tl+
141 rr11 apPlirnblr aril penQ$(1-r.Cnunra,S140e,YlrialWe.11yaC6 re,Clr.)
3.Well Use(ehceicwdl ase); t7:s(:RiEN
Water supply Well: FRONT I TO DtAM TFIt 5WTSI7,E TNICK14M I NIATRRIAL
❑ilgriculttual Mfuaicipalftblic 341 R. 2001 R, 6" in, 020 Schedule 40Stainless Steel
®Geothermal(IleatinglCooling Supply DResidentialVater Supply(single) fL I It in'
®bidustrial/Conunercial ©Residential Water Supply(shared) 'to GROUT
FRONT To NL\TERGL EMPLACENTENT IFMOD&AMOUNT
ohligation 0 fr. 261 fL. Portland C fection
Non-Water Supply Well:
tt. rL
®Monitoring QReCON-cry
Injection Well: R- re,
❑AquiferRcchargc 0 roundwaterRemcdiation 19:SANDIGRAVELPACK fifalqflicAbILY,
sRONr T(r M1TATF,Rt4r. HNlr1A('F:Ni\TH►THpn
❑Aipaifcr Storage arid Recovery QSalinityEarricr 311 fr. 2001 it, Filtered Sand #3
❑Agxu(crTcst QStoramatcrDra1mgC
❑Experimental Technology 13'subsidcr►cc Control
20:DRiGLI1\C'LOG(attach addltion�al nliceldif tnccssan•
❑GeodIctuad(Closed Loop) ❑Tracer FROM 'M DESCRnTUD\mbr,ant dnev soli-rock 1 , 'n wk N dal
❑Geotlaemral(FIeatin VCooRng Retum) []Other(esplaitt under 921 Rewatts) o- fL 1001 iL Brown silty sand
100- (L 2001 fL Rock —
4.DateWells)Coulpleted: 10-27-2022r cl1W#RTRM 22-413 - �'-"
ft. ft. 'f
En
Se,.Well Location: fL fL N
ov
Albemarle ft. ft. �'
Fac ityotMvocrNamc Facr7ity1W(ifapplimble) R. ft. �t3ie - r-.-- C�l
348 Holiday Inn Dr. Rings Mountain, NC 28086 Cleve, R. fL
Plnskal Addccss.City-and Zip 121-Rl:WUWS
Bentonite Seal from 261-311
Coanly Auto Idi.nliftcallan No,(PIN)
Sb.Latitude and Lquigitude in degrecs/minutes/seconds or decimal degr'ecs: 22.Certification:
(lfuoll Wd,wx IaD7orig bs,afucicrd)
35.2257 N -81.3575 10/30/2022
Signatum of Ceitificd Well Contactor Date
6.Is(are)the well(s); glPennanent Or ❑Temporary By signing Ikfx form,1 hereby Terrify Thar Me srd)(s)vox(wrne)canvinrered ur accordance
with 15A,YCAC 02C.01(k7 or 15A NCAC 02C,0:(47 11elf Comirardo4 SlarRlards and r1yua
7.Is'tltis a repairto an edstingwell: oVev or ENn CtVyofrhir remni has beal pmvith-d ro lhr sny1l miner,
ifWs it a repair,fill out kaoirlt wall eonymwdoa brforat fire dyad explain the tutrare of die
repair underd31 ronarls srclion or an ME bark-of Mir form- 23.Site diagram or additional well details:
You may use(he back of this page to provide additional well site details or well
8.Nuutber of wells constructed: 1 constmction dewily. You may also attach additional pages if necessary.
For;4drl pie lq*rlon or'aan-starer supply wells ONLY mirh rile same C017WIrclitnt,}Kau ema
subma one fowl. SUDNIITTAL INSTUCTIONS
9.Total well depth behove land surface:. 200 (D,) 2.1a. For all Wells: Submit This form within 30 days of comptetion of well
For rnnirlple wells list all deprbs lfd{Qerew(exwxple-3@200'a1u12@ 100'y construction to the fotlolsing;
10.Static water level below top of casing; (t1,) Divisiuu of Water Resources,Information Processing Unit,
lfitwer level is ahave cusiag.use"+" 1617 Mail Senice Center,Raleigh,NC 27699-I617
11,Borehole diameter.lo" (in.) tab.Fnr Fnfectlon 1,4e.11c ONLY: In addition to sending the foml to the address in
246 above, also submit a copy of this form within 30 days of completion of%%ell
12.Well construction method:HSA/Air Rotary conshuctiosh to the following:
(Lc.auger.mian•,cable,direa push ctc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY- 1i636 Moil Service Center,Raleigh,NC 27699-1636
13a.Vidd(gpm) Method of test: 24c-For Water Supply&Injectlon Wells:
Also submit one copy of this fonn within 30 days of completion of
13h.Disinfection typm Amount: well construction to the county hcahth department of the county where
constructed.
FarmGW-1. NoahCamtnaDtlkwinemofEnvironurtoant,"Lana!Resources-Division ofWmcrResaurcm Revised August-V13