GW1-2023-01497_Well Construction - GW1_20230209

L CONSTRUCTION RECORD (GW-1) For Internal Use Only:
tl C/ /..oyntractor Informatioon::G_ e 4,2&
Well Contractor Name FROM I TO DESCRIPTION
NC Well Couaactor Certifi 'on Number
r� I� f ��I AROAA tv uumsiax riucxrr�M MAiewA.
ra god l 0 ,R 0 ft. ;,A.
Company Name ,� v� s:: + ia•..w
2.Well Construction Permit#: r_ 00IL& FROM TO DIAKIM rfficxN$as
List all applicable well construction permits(i,e.UIC County,State,&40,41cj ft. (.1 ft' jo (/
3.Well Use(check well use): iZ ft. to.
;. .!�., ,., ,r "''��6s""�t`tltfi°:Y•', s .�_.;'^.'.,_, .fi y_,r.„r
Watersupply Well: spntor Tn v DUMYTER SLOT SIZE THICKNESS MATERIAL
1[]Agricultural [] 'pal/Public fr ft. in. #
QUeothermai(1.leatmg/U001ing supply) esldentlal Water Supply(single) - ft tn.
pindustriaUCommercial []Residential Water Supply(shared) y ae w c gv,
[]Irri on ; Owells>100,000 GPD FROM I TO MATERLAL EMPLACLM OD&AMOUNT
Nun-water Supply well: ft. 2® ft. ( q raV,ty
OMonitodng ORecoveryft. R
Zzlectlon well. ft. ft.
❑Aquifer Recharge 130roundwater Remediation ,...•:..:,.-...: „ .,,..... _:. _<..v .,:;.;; , :.;•;,,...-,., ,,�.-, x
❑Aquifer Storage and Recovery ❑Salinity Barrier r EMPI.ACttMENI METHOD
MAgaifer Test OStormwater Drainage
OExperimeutal Technology ❑Subsidence Control 1I. ft•
pGcothermal(Closed Loop) []Tracer
❑Geothermal(Heating/CoolingReturn ❑Other lain under#21 Remarks) FROM To D76aCRTFr1ON cater et a
is 0 ft.
4.Date Wefl(s)Completed: Q Well ID# ft' ftqr4nife Co c
1r. ft
za.weu ,ucauua' -
3
Faaffity/Owner Name ii Faoility IN(if applicable) ft % i
it
PhPiz
ity,and Zip ft. fL ) .
,.:'..
County Parcel Identillcation No.(PIN)
bop
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' L
N W ZZ
1P 6.Is(are)the well($): 19ermanent or []Temporary of Certified Well ctor l Data
By signing this form,I hereby certify that the we11(s)was(ware)contracted in accordance with
7.Is this a repair to an existing well: []Yes or QI3 0 13A NCAC 02C.0100 or 13A NCAC 02C.0a00 Well Construction Mando dr and that a copy
.Vihk is a nrpair,fill out known well construction information and explain the native of the of this record has been provided to the well.owner.
Moir under#2I remarks section or on the back ofthis form. ­______ _.-,.._I:n=
R,For Yennrniti•/13PT nr Clnxed-Lann Geothermal Wells havinv the same You may use the back of this page to provide additional well construction info
eonstru ,only 1 GW-t is Deeded. Indicate TOTAL NUMBER of welts knuu w c vvu w"""'"u"oval. i vu a,ay awu uuacil niuiiuuueS Pagw ii ua caam.
dn11 : 24.SUBMITTAL INSTRUCTIONS
9.Tatal well depth below land surface: (it.)
For multiple wells lit all depths y'd fflkv t(ownple-3Q200'and 2®100� 3nbmit this GW-2 within 30 days of well completion per the following:
tatic water level below top of casing: 2-Q ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.3
10 r level to above easing,use + Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: t r rolqrX 24c.For Water Su and en-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,arc.) county environmentaal health department o co�inste
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells iDrodudns over 100,000 GPD: Copy to DWR,CCPCUA
f9� Pertnit gram,1 S Raleigh,13a.Yield(Um) `�.d..�• Method of test:
13b.Disinfection type: / •1 Amount: �"