GW1-2022-10666_Well Construction - GW1_20221128

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
io�
J`'`m i�.v� C( +blCV� 14.WATER ZON ES
FROM To DESCRM014
)Veli CanttactorNmne fL O lt•
NC1Vell Coutracttoor Cedi�f ccation Number ir_OUT=CAMG Mr MUM waced Mve s)OT;LUM ttr
FROM To I DL1ht M TR(CKNESS I MAMMAL
Company Name 16.INu+ 4NGUl3TtURIRGf t�alclas�•]oo )
2.Well Construction 1'el`mit S:__�(�U t:ROMi" -Tn n��• TlltclaMS MTE AL
Litt all applirallle well construction permits fix.UIC.Cotuay.Stale,Variance,etc.) h. b ii'. .4,�S in. SDE Z P✓C-.,
3.Well Use(check well use): ft-. ft- ! I 'n-
Water Supply Well: 17.SC'REEN1
FROM I TO I DMAHMER I SLOT SME I TmctA1m htATERW.
Agricultural qMcjpaVftblic
R. ft. in.
i Geothermal(HeatinglCooling Supply) enGai Water Supply(single) • ft• �.
industriallCommercial E311esidential Water Supply(shared) is.GROUT
I 1lTi attOn FROM TO 'NUTEMAL EN IMACE.41E\\ AMBOD&AMOUNT
Non-Water Supply Welk ft• 2 p ft•
Monitoring Recovery ft. It.
Ftdection Well:
rluifer Recharge DGmundwater Remediation
19.SANIDIGRAVEi.PAQ, livable .
Aquifer Storage and Recovery DSalintty Barrier FRO31 170 anaTERML MMq ACtri nrhT MEMOD
AquiferTest E)StotmwatcrDrainage
Experimental Technology OSubsidence Control it, fL
Geothermal(Closed Loop) DTraccr 2ll.DRILiMLOG(ottaehaddtttonals6at5if
FROM TO , DESCRIPTION(mlar.bardoels,soilftack siu.etrl
GcathetRutl(Hcatin lCoolin Return) Qther(ex lain under d21 Remad(s) fr. &0 tt.
4.Date Well(s)Completed: ` g- Well M# 60 ft• 2 s R.
VA n
Sa.Well Locution;
Za.n
FacuitylownerName Faci1i 16B(ifn livable}
0 Dgev T1�ttr� Trail i LeAld L Lw tik. 2 S'IL(to ft' AIR 9022
Physical Address,City,andZip ft. L
LIyWYr AI.RF.MARIiS
County �SY PatrelIdentiGeationDIo.(Pli� V J "RN
3b.Latitude and longitude in degreWminutealseconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
Of -V' 44.031tzleH gZ�s' 6L0Ks'4429''r W �Vatuw,-
By6.Is(are)the weli(s) ermanent or Temporary eRi6ed Well Coottactor Datu
signing this forah,f hereby certify that lire w alt(s)nos fivere)corutracted in accordance
7.Is this a repair to an existing well: 13Yes or DIN10,
uilh 15A NCAC 02C.0100 or 15ANCAC 02C.0200 lVell Catwruction Standards and that a
If dus is a repair,rlt out known well construction inform ain the nature ofthe copy of this record has been prortded to the well otmer_
repair under021 remarks section or onthe back ofMisfomt. 23.Site diagram or additional well details.
8.For GeoprobelUPT 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 nccdcd. Indicate TOTALriUMBER of wens eonstYueuon detwU-You may also anneh additional pagea ifueeosaary.
drilled: S liiR a; INSER r ptir4s
9.Total well depth below land surface: q ( ) 24a.For All Wells: Submit this form within 30 days of completion of well
For nuthipte icells hurt all depths if df ereitt(emmplr 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 uYtter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699.1617
ILBorehole diameter: t'e 2 (in.) 24b.For Iniection Wells: In,addition to sending the form to the address in 24a
�O�Q 4 above,also submit one copy of this form within 30 days of completion of well
L?.Well construction method: - CODStnteti0n to the fallowing:
(Le.user.rotary,cabte,di=push,etc)
Division of Wider Resourc es,Underground Irdection Control Program,
FOR WATER SUPPLY WELLS ONLY; 1636 AM Stsvice Center,Ra]fth,NC 276991616
13a.Yield(gpm) 1 Z- Method of test: l�r N)- 24c.Ew Water Su &&Infection We In addition to sending the form to
p the address(cs) above,also submit one copy of this form widda 30 days of
13b.Disinfection type: �' ,IOrtYtJl Amount: 1 completion of well construction to the county health department of the county
where constructed,