GW1-2023-01005_Well Construction - GW1_20230125

WELL CONSTRUCTION RLCORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
Cn FROM it) DESL`R1Pff0ii
Welt CotttracxtorNamz Q ft. -qS It. , , 1t
V
' ft. It.
NC�VPJICantractorCettiFcationMurnber IS.OUTER CASII�tG(fhrmu}d-cased VMJs)01tLINERfif )
FROM ft.
TO R. DFAttitElE>}in. IMCHNIM MMUM111AL
Company Name 16.]MME I CASING OflTt7B3NG(eatthecmai dosed l )
Z.Wet!Conshvetlon Pennit 9: 4 1 jp gl FROM m DrAMM �ifctaa�ss r,�
Litt Ott appticable well cnnsiniction parmits(i e.UIC.Comity.Ywre,variance,etc.) C) l.f R• (�t Z S' in. C N S Mir
3.1YeU Use(check well ruse): ft. ft. in.
Water Supply Well: 17.SCREEN
F13oSi To DIAht13MP I xr-ore v TSICI;IVESS giATpR1Ai
Agricultural uuccipal/Public ft.
Oeothcrmal(Heating/Cooling Supply) 9KesidenGai Water supply(oagle) M
Industrial/CounmercialLjResiden6al Water Supply(shared) GROUT
lilt Orion FROM To iFrATettrAl, n�Ac �TirtrsrrxoD�utocnT
N=3ter Supply Well: 0 R' o2
MonitorinH DRecovery
Itdection Well:
ft. tt.
Aquifer Recharge E3t mundwaterRemediation
QuifetStorage and Recovery Salinity Barrier �oiYNDIt ANELPACK of ble
3ffATFBLtL IIHPLACE►1 NT alEMOD
AquiferTest 05tormwalerDlainage ft.
Fatperimental Technology j3Subsidencc Control
Geothermal(ClescdLoop) DTlaccr MDRMST'IGLOG(ottachadditlonelsheaslr
D Gcothetmal(Heatin /Coolie Rctant) Other( lainwtder#�i Remarks) FRG-M TQ nLccl2lPrloAttminr banlaets,murtark a ze�)
o � 1 yam`• C► l o g �, .
4.Date Well(p)Completed: 7`Z 3 Well M s—tt. �—ft. C,
Sn.Well Location: �• tt• ~�, e 6m 6 V
G-"A')tl NG.L(Y1 fu It. 9 9
Pacllityl0waerName FaeirayID#(itapplicable) ft. fL V-
19,29 lh o tit') ib u n /1 YG C( {l M It' 1f24 ff i i'l terra^,t:w�Ca sd3
Physical Address,City,and Zip fL ft
181,c�1� .•. 711010 40 ILRMWAM
Caltal}'
Parcel IdentilicationlNo_(PINJ
Sb.Latitude and longitude in degrees/tninuteslseconds or decimal degrees:
Owell Held,one latllong 1s sufficient)
22,Cortifit:ntion:
',)6.gn3 s-Zi'IN g-I._qq ,5g.0 3 c(eiff it W _
6.Ts(at'e)the well(s) ertasnent or OTemporarg tureo€CcrtifiedNeIICoatrdstar Date
By signing dkfs form,I hereby eettffp That[he uellfs)uns(3vere)ctu eructed in accordance
7.Is this 3 repair to 8n e:tistfng well: E3Yes or EDMa' xith ISA NCAC 0247.01a0 or 15ANCAC 02C.0200 lire!!Canstructivn Standards and that a
Ift his is a repair,fat out ta:oun u%-U construction information and explain the nature ofthe COPY ofthisrecord has been pravided to the.vel!airner,
repair under 021 remarksserliott or on the had-ofthisforns. 23.Site agrum or additional well details:
R-liar C'eoprobeJIDPT or Closed-E oog Ceothermal Wa613avias the satnc You may no the back of this page to provide additionnt wan site dcro ns or wca
construction,only 1 OW-1 is nccdcd. Indicate TOTALNubmwL ofwells eanstiaction detmb-You may also attaeh additional pages ifae'aa=asy.
drilled:
� fi[3Rfldi'!•TAi itVfiTRi Cl7®101fi
9.Total well depth below land surface: 0 S (ft) 7¢g,For All Wells Submit this form within 30 mr days of completion of well
For I Ve treks I&all deptlu lF&Prent(emmpte-3@100'and2@100) construction to the following:
10.Static water level helow top of casing: (0 (ft.) Division of WaterRmurces,Information pros
If enter lemlfs abore easing,use"+" Ott
1517 Dail Service Centtr,Raleigh,NC 276991617
II.Borehole diameter' �a2 s— --dn.) 24b.l+'ar Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:-Idalz above,also submit one copy of this form within 30 days of completion of well
04-auger,mtatg,cebie,dlteetpu94 ue) constiucam to the following:
Division of Water ReNO rces,UntlUgromtd IDjecfion Control Ptugralo,
TOR WlkTER SUPPLY�yl;l.T c ONLY: 1636 Mail SmVp Ceater,Italeigh,NC 27699.1.636
130.Yield(Rpm) 9 Method of test; 6ial. CO t ,P 2&For Water Stmnly&Inircfintt WeIL' In addition to sending the form to
f the addle ss(es) above, also submit one copy of this form lvidlin 30 days of
13h.Disinfeetiontype: C61�OY►hQ Amuuntt 6 7T�b_ completion of well eonswiction to the cou y health department of the county
where constructed.