GW1-2023-01742_Well Construction - GW1_20230213

WELL CONSTRUCTION RECQItD Gt�'-1
For Internal Use Only: —
i.'+Yeli Contractor Information; �—
14,WAILK ZONES
WeiiContnnvrName ruoM TO _ uescalrno,
A)
NC Act)Contractorccmficaux t cur. - IS OUTER CASING for aralli cx" wens OR L1- nra ncable—
�� _ y y 1��� FROMn To it a1,1.NETF.R in. TInCx�1eT3 ,u71?RIAIA
Ito
Corrg+anyName 16jINNER CASING OR TUBING mthermd 1m
_�' —__
2.W'eil Construction Permit#: WSt�+lf�^M�(}�?q�— raOM 7T/ �I DtAML1TR I fttiCKvi55 tllTf.Rl1l
lisr aYJ nypticable rrll cautrwet+nn fteratitJ lie Ct7G Couam,Stute,lar,ance,ru; fL ft. In.
3.Well Use(check well use): n. ft. In -
Wa ter Supply Well: 17.SCREEN —
f'n()M TO DIAMETER $LOI S ZE THICKNESS MATLRIAL
OAiculnral LMunicipal'Rtblic ft. ft. in.
CGeothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft. � ft. � In.
ClrldustriaUC'ommercial CResidenlial Water Supply(shared) l8-GROUT —
OlTri atiotl L7Wells>ILM,f) l6141) sxON To >tAITR.rAt. runtAcfstE.T+r._r11111) 4.MOLN°?
Non-Water Supply WeB: f R. Q n — �`
ur
aMonttoring CRecevuy ft. n.
Injection Well: —
tt. ft.
CAquifer Recharge OGroundw•ater Rcmcdiation —
19.SANDIGRAt EL PACK if a pl catrlel
CAz)uiler Storage and Recovery L1Salinity flamer FROM TO MATERLAI _ (sIPI ACESICv7 NETHOa
C tquiferTest i OStormwater114ainage d n. -7 ft.
ClExperimevtal Technology CSubsidence Coutmi n. L ft.
00tothermal(Closed Loop) L31rracer 20.BRILLC G LOG(attach additional sbccts ifaecosar))
iHO;yt TO a6SC7i1PT10N teefoR Aardntt�soikeoex t o In>Sa.ac
❑Cseotherinal(Heating/CoolingReturn) 00ther(explain under 421 Remarks) H� t e;^
d.Hate Well(s)Completed: iCf`. _2 tAe1l lDit n.
53.Well Location: ,ry ft. n.
FaciOtyrOwner Name 1-acibty IDa(it applicable) n, M
fL�7E7 ihit1 t�19t��>� h� k4c t rIt. --
-
Physical Address,City.aM Zits ft. n,
Cs_amtr}, Perttildcoiift[acrnn No iPINt --.-----
5b.Latitude and longitude in degrets;minuteuseetlnds or decimal degrees: --
(ifwcll field.one tat;]MIS i,FSuIficicntI 22.Cert cation:
6.Is(are)the weit(s): • ermanent or L7Ttmporary
Stgnatu t cf Cenrfted A'dl Contractor Dare
Bc.tJgnfag this farm.lhtrahsy eerttjv that tlrr wrttfil tt+vl-wet cows—wdtit wen 47arr rith
7.is this a repair to an existing Fell: UYw or o lid XCACO2C Of00 ar 134 A` ACO2C 0.00 Well Covrrvcvroa,Gandarrlr end tkar>,t,r,-
/f tltfa is u repoir,jLl gut knon»•r aa•If rnasttacttan iti(arntnrton nrv!es{da,n erne rsnwr r of th
j uns ward?rma:a;n prav±drd to the nrtl asmrr
repair rrndn 021 rmarks srrs/an or on the pork at fltoJsm 71 Site diagram or additional well details:
Geothernnal Wells iwvin tier unto You rnuy use the back of this page to provide additional Nell construction info
S.For Geoprobe/UPT or Closed-Loop F (add'See Over in Remarks Box).You may afro auaeh additional des ifneressarv,
construction,only 1 Cite'-1 is needed. indicate TOTAL,NUMBER c,f%ros
drilled:___,_..._—- 24.SURIIITTAL INS9-Rliurl02yS
9.Total well depth below land surface: (ft') Subtnit this C%%-1 within all days of well cangiletion per the follw+tug:
F'dr nrainple—III list 01f drptks if difJerenf(r.w1 rle-36grlfN)'aaJ aajlOft`)
24s. for .tR Wells: [higinai t'iusn to C)visiCan of st`atcr Resvtrtctis (f]N'R),
10,Slatic water level below top of casing: (fi•) Inf,ro;:oo t Pnkcssh,g Unit,1617%ISC.Raleigh,NC-17690.1617
if—ter lrrel rs-1,-w resin;use"•
74b.For injection Wells:Copy to DN`k,Clnde4gtound injection Control(IUC•)
I I.Borehole diameter: � (in.) Profrant.1636 MSC,Ral.-igh,NC 27694-16-16
V d L��sYT 1 24c.For water Su t and O ru-L Grothermal Mora Wags:Copy to the
.c well construction method: �� _ P�,c.71r, 1'�—— ty
t i.a sugar,rotary,cable,dverr pruh,nr i county rnvmnuneuta hen t t - anmrnt o the coon where-- installed
F13-.'1V1r'Ie1d
TF,R SUPPLY IVEL L ONLY: 74d.For WNW Wells Itroduetn over 100 0� 4^M Copy to D%Vk,CC}CUA
Permit Pn -�I,I( i 415(, R..etgh,A'_r6 9-161
(gpro) >� Atenfection type: �h�
Form Gw-1
North Cawhna fkpswn vm ut tianrtnma:atal C)aality-pirs,m,of vl amr Rest-ces Rcv,sed 6-6.201$