GW1-2022-10616_Well Construction - GW1_20221122

WEU CONSTRUCTION RECORD WW-1) For Internal Use Only:
1.Well Contractbi'Information: —�
A4.YPATERZONES I
Well ContractorName FROM 170 t DESCRIPTION
ro� C7
NC Well Contrac or Certification Number :25.'0Vr1 i;CA3I1W I'ta,'muttr aSetl we ]Finns-- eaaT
FROM I To I DIAMETER ` hTERIAL
fL in.
CompanyName I&INNER CASING ORTQSlN f thermal closed foo
2.Well Construction Permit#: FROM I To I DIANRIER I THICKNESS I MATERIAL
List all applicable well constntedon permits(I e.Ufa County.State.Variance,etc) ft. ff in.
3.Well Use(check welt use): ft I in.
Water Supply Well: 17.SCREEN _
FROM TO DIAMETER SLOTSIZK THTCENM I MATERIAL
Agricultural [)M pdT b1i p LL in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared) Is.GROUT
Irrigation --- FROM To MATERIAL EMPLACE. METHOD&AMOUNT
Non-Water Supply Well:
c
oultoring DRecovery I ft. G 1
Nection Well:
ft. ft.
Aqui&Recharge DGroundwaterRemediation 19.SAND/GRAYELPACI;,f6 llcable
AquiferStorage and Recovery E3SalinityBarrier FROM I To I MTr rIAL. I SMPLACEMENTMETHOD
Aquifer Test FIStormwaterDrainegge ft. f-
Experimental Technology OSubsidence Control fL a- l
Geothermal(Closed Loop) OTracer 20.DRII LING LOG attach additional sheets ifn
-
0'Geothermal(Heating/Cooling Retum) Other(explain under-42IRemarks) ft To
4.Date Wells)Completed:10 jffi -ry VA
5a.WellLocation: ft.
nsserRm TToxr�lornocanrs,wnr�ex atzaaal
6
t .. ',
FaoilitylOsvnerName —�— FacSitylIJ#(ifapplitxble) ft. ft. �e ¢ ;—
L ft. ft. V 2 2 2022
Pliysied Address.City,and Zip M ft.
Lrs,24 21.REKARSS {I14vine:a�J,,• „'
.J
e
County c FarcelIdentificationNo.(PRO
0
5b.Latitude and longitude in degreestminuteslseconds or decimal degrees-
(ifwellfield,oneladlongissufcient) 22.0 Lion:
-3y,90 . LAN Z�°T-�°�f,� Ste' W -2-7.
6.Is(are)the well(s) rmanent or OTemporary e of Certified Well Ca actor Date
� B}�s/igning this form,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an eidsting well: 13Yes or Ea""' ivith 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known welt constructiorz information and explain the nala a of die copy of zhis record has been provided to the well owner.
repair corder#21 remarks section or on the back of thisform.
23.Situ diagram or additional well details-
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages if necessary_
drilled: /— SUBMITTAL U49MUMONS
(�
9.Total well depth below land surface: / (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(a)200'and 2Qa 100)
constmction t0 the following:
10.Statie water level below top of casing: 2,5" {ft) Division of Water Resources,Information Processing Unit,
Ifuuter level is above casing,use"+'� r 1617 Mail Service Center,Raleigh,NC 27699-1617
11.13orehole diameter: (0�g (in) 24b.For Iniection 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: to construction to the following.
(.e.-get.rotary,-ble,direct push,eta.)
Division of WaterResources,Underground k ection Control Program,
FOR WATER SUPPLY WELLS ONLY: _ 1636 Mail Service Ceater,galeigh;loTC 276991636
13a.Yield(gpm) 7(J Method of test-F n' .For Water&D&&Inieetion Wetly In addition to sending the form to
y� the address(es) above, also!submit one copy of this foi within 30 days of
13b.Disinfeetion type: Amount: (� Del h riGS m completion of well construction to the county health department of the county
where contacted.
Fora GW-1 North CamlinaDepartmentefEavimnmentdQnality-Divis&m ofwatcrResonrces Revised 2 22 2016