GW1-2023-02061_Well Construction - GW1_20230303

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WELL CONSTR TCTION RECORD(GW-t) Forinter I IIse Only: -
1.Well Contractor Information:
RillL !
���a��� �I4.iVATE1LZC}1?D:S
`ireliCanaactorName MOM TO: - DESCRIPTION
Li 0 A- ' 2-2c) 2 Zz ft' 9r't", 9f-Qe;-c/%Z.6AI1„
ft. I i fr.
NC Well Contractor CerfificatiouNumber
rjv� !j well
j } r j j 15.OLThltCASING(for multi-eased wells)ORWIER(i£up livable) .
,ff ( eJ! fir/i j.'! lRonr To: DIAMETER THICKNESS MATERIAL
Company Name _ 1-I ft; �60 I
G fn' -21 PVC
g.L�2 7(/ 16.1R'I4ER CASING ORTtIBING{geothermal closed-loopl
Z.Well ConstructiouPermiE#: OL) QQ xRolti TO, - DIAMETER THICKNESS MATERIAL
Gut all applicable mil constructionpennirs(i.e.EhIG Count};Stare,Variance,etc) €t: I , ft in.
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3.Well Use(chesitwel[irse): ft` H. M.
aterSnnply Well: 17.SCREEPi I I • -
Agricultural PROM TO ' DIAMETER SLOT SIZE THICKNESS MATER
i` unicipal/Public ft; I , ft in.
Geothermal(Heating/CoolingSupply) iRtsidentialWater Supply(single) R , in,
• N : •Indnstrial/Commercial [IResidential Water Supply(shared) I
18.GROUT I .
Imgatian FROM TO MATERIAL. EMPLACEMENT METHOD&AM
Non-Water Supply Well: 0 f. 20 ft, chip. ,c Monitoring Recov f° i
Injection Well: Y •
ft, I i ft.
ft.
I ft'
Aquifer Recharge OGroundwaterRemediation
Aquifer Storage and Recovery19•SAND/GRAVEL PACIKfif applcabte) -
Ell PROM ' TO, I MATERIAL EMPLACEl1 oirMETHOL
Aquifer Test DIStormwater Drainage ft. I 1 ff.
Expedmental Technology 0Subsideuce Control ft. I ' it. .
Geothermal(Closed Loop) QtTtacer 20.DRILLING-LOG(attach additional sheets ifnecessaryl
Geothermal(1:Ieating/CooliingReturn) DI Other(explainvnder021 Remarks) O I TO DESCRIPTION(color.hardness,soillmcktvpa araln size
G " sa it. Dri-
j 4.Date Well(s)Completed:l f 30-22 Wen ilk# �G 6 7 ft' 9P 1y y 1't i
5a.Wellbocation: 16' IL' 4°5_ ft; l ohtkgrAn k
Hoot Morale,' 406 ft- OP f: ii nles)are/gr> ,irefmk.
EactfttylOwnerName FactlitylD#(ifapplicatle) I •R
5I0 w/ll4pkDc/ bbw,v ibck . I .s ..r° .� ;r` s
Physical Addtr.%City,and Zip ft- I it
•v ecy
21,BEVIABI S MAR '� L CrLJ
/�-
County . PazzelIdentiificatiouNe.(P1N) I !r,?,-.- ;::;"•n :,;-.r,..,,.:.,, i Ir.
51r.Latitude and longitude in degrees/minutes/seconds or decimal degrees: °'`} i
(if well Hld,jt atnoogissulficient) -
Ic 22.Certiticati4 •
36.G1Iosr N g-J 7'Z3-2 w
�' ' )13012
6.Is(are)the wall(s)MI'ermanent or 01Temporary Signature ofCeefiedWVeU dnr Date
By signing this font,I hereby certify that the imll(r)was(were)coasrnrcted in ace
7_Is this a repair to an esistingwelit Q.Yes or with 114 NCAC 12C.0100 or JSii NC44C 02C.0200 Well Construction Standards ar,
Obis is a reaa,full our known well construction Wnformationanti es,lain rite nature ofthe c°P74.1111Tecarr hasbeenpmvided to the rrelt owner-
repair under#21 remarks section or on the back ofthisforac
I 23.Site diagram.or additional well details:
I S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use tle'back of this page to provide additional well site derails
i construction,only 1 GW-1 is needed_ Indicate TOTAL NUMBER of wells construction details.You may also aitaclmadditional gages i£necessaly,
drilled: SITSMITTA ,INSTRUCTIONS
(TO� I
9.anal Total well depth list below land surface:(-, (ff) 24a.For All�VeIIs: Submit this foram within 30 days of completion
Forrauhtiple wells list all depths ffdifferent(example-3(r 00'and 2(�a 100�
I construction to khe following:
j10.Static water level below top of casing: I�S) (if) Division ofWater Resources,Information Processing Unit,
'Ifciater level is above casing use"-!^ 16l7Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:Gll3 qq j�(in) ••2fib_For Iniecl(m'on Wells: In addition to sending the fom•to the address
12.Well construction method: t'-lt r I�Q�OU(d above,also sulimit-one copy of this form within 30 days of completion
i 6.e nuge,mty,ta cable,direct push,etc.} construction#o i efoliowin,;
FOR WATER SUPPLYWh LT,S ONLY: Division of Water Resources,UndergroundIi jection.Control Progr
I 136 Mail Service Center,Raleigh,NC 27699-1636
13a.Meld(gpm) Z Method of test:Air L j f)-- 24e.For Water Supply&Injection Wells: In addition to sending the:
I 13b.Disinfeetianfppe: ���� the address(es)Iabove, also submit one copy of this form within 30 t
I I Amount_ completion of well construction to the county health department of the
. N where constructed.
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