GW1-2023-01403_Well Construction - GW1_20230208

WELL CONSTRUCTION RECORD(GW-11 For Internal use On y:
1.Well Contractor Ttti'ormadon:
b y1 �D(S i .WATER gore f
well Coatmcwr Name mom TO ledva)
ON
NO Well CW=wr Cerdfioadon N -
P 15.OUM-C f3 orORL'IM ff emit")
rLt I 1 u VROM 'M DUNE= TMCN?4= MATE&IAI.
Cum Name Q
DOMR
2.Well C'owtruetlon Permit#:
Q/ mm MIT
MGM TO DUNE= cM I MATFn1At.
List all applic0le•weil construction permits(Le,WC,Cotoo,,bYrtte,Parlance,etc,) Ito.
3.Well Use(check well use): t#• n• t°'
Water Supply Well-. 1..SCREEN'
A,grlcultutal unioipai/Public FROM TO DIAMETER 'SLOT UM T CKNM MATERIAL.
ft. fL fa,
Geotltemtal mcadng/Cooling Supply) Residential Water Supply(single)
hrduattwCommorciai 0P.Wdential Water Supply(shared) rt8. OUT
kd dos K rnOL o a ot/xr
Non-Water Supply wens R' 4 n'
Monitoring Recovery r,
injection fr.
Aquif ftharge 0GaoundweterRemediatfon x4:1iAFID/f3RA PACK E to
=SU
rage and Recovery Salinity Barrier onLMaTE4tut SMPLACEM6fPr1YIETAOD
Aq Test C)Stotmwater bsainage R• r• j
Bxpernmcatal Technology C)Subeidence Control fit, ft.
Geothemaal(Closed Loop) C)Ttaoer 20.DRTI,L INO. . G h addition tE
Geothermal tin Coo Return) Otter n tmtler#Z1 Remarks TO n or olor, M + d.
4.Date Well(e)Compiatedt I a�`�` Well ID0 to ft. q o % G
SQ.
S1�T`Y'1 � C.U�'6�[ M � 200'� GO ft.
Facility/Owner Name FacilityID#(ifepplTcable) ft: ft. � #o a x�v"l
39 a ! �� Cr®ss1 pus �f P l�p�x FEB
PhysicatAddress tSty,and Zip ft. R.
P,Q. .ate.~IF fit
Courtly ParcelldesaiHeadouNo.(PIIN)
5b.Latitude and longltade in degrees/minutes/aeeondg or decimal degt'ees: f
(if+vell field,ooe k0mg is sutlielent) 22.Cemeatlon:
N W 1911 - J _ Z2-
6.U(am)the well(s)6Permanent or QTemporary 8lglahar f C.eracd W Cantracwr �—" >hft I
By alphW dds foma I uereby certify dune the imll(s)ivas(awr)comfteted in acemdwce
7.Is this a repair to an eilating well: 13Yes or 04 with ISA NCAC 02C.0I00 or ISA NUC 02C.0200 A'ell Canw/mdkn gandards and dw a
If tuts isa repalr,Jill otrt kMff WN cvnsttru/ion h formation and explain the nawre ofihe copy ofthk Neord/ws keen FmWed to'rue welt awaer.
►r'pairtrader t121 remarkaectdon or on the back ofthds farm,
21 Site diagram or additional well detalls:
8.For Geoprobe/DPT or Clewed-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 GW 1 is needed. Indicate TOTAL MjhMR of wells construction details. You may Oso'attach additional pages ifnecessary.
drilled: i �o g�Ai,xNS�TRi t'rIONS i
9,Total well depth below lead surface: o (B•) ?,4a. For ii Walla: Submit fuss tbrm within 30 des of completion of well
Pop multiple wells list all depths p dOTerent(arample-3@Z00'and Z@I009 construction to the following: f
10.Static water lave:below top of casing: 2,0 (ft) p)�n of Water Reaoprcec,Information Procasiug UrA
t7water level is'above casing use..+' 1617 Mall Service Center Rat eigh,.1VC 17699-1617
11.Borehole diameter: 7 _ (in.) Ub.Fol lu,latm,`Wells: In add IItion to sending the form to the address in?Aa
above,also submit ona copy of i'slibrm within 30 days of completion of well
12 Well construction cable, method: I r construction to dw following:
(i.a auger,many,cable,ditvcr posh,axJ i
FOR WATER S(JPPLY WELLS ONLY: D1VWu of Water Resources,UndeLgromtd Injection Control Program,
1636 Matt Service C`enter,Raleigh,NC Z76"-11fti6
13a.Yield(gpm) Method of tesh �`"' ?Ac.For Water Sudaly&Ynlectio I Wells: In addition to sending the form to
the address(ea)'above, also submit Joao copy of this fo= within 30 days.of
13b Disinthctlon type: Amount-_(� completion of well construction to i county health department of the county
(:ni
where constructed I -
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