GW1-2023-02108_Well Construction - GW1_20230303

II .
For Internal Vse Only: -
WELL CONSTRUCTION RECORD(GW-1).
1.Well Contractor Information:
• P6-19 L P,,t ✓T2c , .
14 WATERIONES
Well Contractor Name PROM �Iro DESCRIPTION
i so - ij 3 ft:
207 lt: alb rt pni
NC Weil Contractor Certification Number ��
Well
35_OUTER OWING(for multi-cased.mia OR LINER.(if a licamle)
Dv iy(5 '3e l Or /j/;tj0 LFROMr T'O^ DIAMETER �THICttiESs MATERIAL
Company Name 1 "f I ft- I Y W ft' G in. 5Yll-21 j Ft,
2.WeitConstrnctioaPermit#- 3�as. � 16. RCASING Olt.TOB G(geathermalclosed closed-Jowl
FROM TO DIAMETKR THICKNESS I MATERIALList all aoplkable well construction permits(I.e.LIIC CommStare,Variance.eta) ft. I , ft. in, (J
3.Well Use(cbesl veRuse): ft. I ft. in.
Water Supply Well: M 17.3ERls)vN I
• I!RO TO ' DIAMETER SLOT SIZE T331eKNaSs MATER
QtAgrlcultural NI .icipal/Pnblic ft, I ft_ in.
Geothermal(Acating/Cooling Supply) ;'esidential-Water Supply(single)
fr. I ft: in.
, ! Industrial/Commercial DResidential Water Supply(shared)
ltl.GROUT I I •
Irrigation FROM2 _TO. MATERIAL EMPLACEMENT METHOD&AM
Non-Water Supply Well: G ft ZO f,
rm
g EftRecovery it. ft. Dry P
Monita
Injection Well:
Aquifer a ft. I ' ft.
9 g oGrormdwaterRemediation
Rquift r Storage and Recovery Sakai Bawer 3.SAND/GRAVEL PACICcif mineable) • -
ty PROM TO MATERIAL - EMPLACEMENT METHOL
Aquifer Test QlStolmwaterDrainage ft. I , ft
Experimental Technology • 01SubsidenceControl ft I IL
Geothermal(Closed Loop) DITiacer 20.DRaLIPIGLoG(attach additional sheets ffnecessanl .
Geothermal(Heating/CoolingReturn) DDOther(explainunder#21 Remarks) mom I DES on[co os,henlness saaJmcrctxre er to size
O ft, IIo ft, e4
4.Date Well(s)Completed: R ZG Z.
mp well m# 11 j n' 220 ft: grey jgoi lt7 LinvsA 7e
5a.Well Location: ` ft I ft
kAkAyilf, CCkble it. I ft
Eaclity/OvnarName �Fac!itityli#(ifappticabie) ft I ft.
01Ck 7Eb{f gn"I{t✓esi-JEcaT70A 26icf
It I , ft: .t.;`:ran<,r• <j Y...'I. ;
Physical Address,City;and Zip f s: I ft
AS)) 13{q& 1i acoac 2I. M S ".4a�' ?L'.�3
_ County . ParcelldentificationNo.(PIN) - I :n f;-:,{zr ...^1 Pr :- .i tin:i
I U;.e Q:ci.�t-:
• Sb.Latitude and longitude in degrees/minuteslseconds or decimal degrees: 1
(if well field,eA t/lang is sufficient)
72.Cerlifieatic
3G.35-01 = N 8I b3'0S w
e....-tbd ::7-1Z.—.........7.--1•
1 6.Is(are)the well(s) rmaaent or ClITemporary Signature afCerritied.Welt uactar Date
By signing�fol rni,I hereby ceri fy that the wells)was(Were)constructed in acc
7.Is this a repair to an existingweut 1.Yes or E Nn with ISAIiCAC 62C.0200 or;SA NG€C 02C-0200 Welt Consinrrtton Standards ar.
1 J[his is repair,jilt ovrkuawn well constraelioaitformatto>r and explain the nature ofthe copy cif thr:"emrki sbeeaprovided to thearelrowner-
repair under r21 remarks section or on the bac&ofrhisform.
23.Site diagram or additional well details:
I S.For Geoprobe(DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details
` ccoinOs ction,only 1 GIN-1 is needed. Indicate TOTAL NUMBER.of wells construction de�is.You may also attach additional pages ifnecessary. •
ed:
�7�,, SLJJ IITTAL IINSTRUCTIONS
9-Total well depth below land surface: 220 24a.For All Wells: Submit this fora within 30 daysof completion
Fortnultiple welts list all depths ifdrffereut(example-3 .200'and2t@a I00� � ) p
. consirnctionw the following:
10.Staticwater level below top ofcasing. 110 (ft) Division ofWaterResources InformationUnit,
I •Ifuaterlevetisabovecasing,use"-ti" eProcessing
�� 117 Mani Service Center,Raleigh,NC 27699-1617
Ii.Bttreholediameter: G cm.) ecru
24b.For ini on Wells: In addition to sending the fotrn•to the address
12.Well construction method_ f ('Y above,also subunit-one copy of this form within 30 days of completion:
i - (ie.auger,rotary,cable,cheer push,etc) / constractionto i e following
FOR WA1Rtt SUPPLY Wb LI S ONLY: Division of water Resources,Underground lnjeetion Control Progr
I 1636 Mail Service Center,Raleigh,NC 27699 1636
1 13a.`field(gpm) Method of test:Air LI f7 24c.For Water Supply-&I'niection Wells: In addition to' I 'J - sending the
4' n� d� the address(es)`above,'also submit one copy of this Rum within 30 c
i3b.Disinfection type: v AIDoant: completion of dell construction to the county health department of the
--where coosttuc i'