GW1-2023-02112_Well Construction - GW1_20230303

It;
WELL CONSTRUCTION RECORD(GWV 1) For Interval!Use Only: -
1.WeH Contractor Information:
14.WATER ZONES
NVell Contractor Name EROl►t'. To I DESCREMON
it dNC Well Contractor Certification Number
/ ) 15.OUTERGASIIdG for could-cased wells ORZII�B if a Rcabte
(y i DfTr J I{�f� FR/OAX TO DIAMETER THICMps MATERIAL
Company Name -11 t V Fc t� in �G
/(�7�4 FROMNEIt CASING----T NG(eothermal closed:loe )
2.Well Construction Permit#: L iJ l ERox lT0 nr,�mT TmclINEss�MhURIAL
Listall applicable melt construction permits(Le.UIG Count};Stare,Variance.etc.) Ft I I ft. in.
3.NMI Use(cheslfwelf use): % I % in
Water Supply Well: 17::SGREEiY"I
Agricultural PROM To' DIAMLTER SLOT SIZC TRICKINESS MATER
pal/Public ft. I ft in.
_. GeotherMEd(Heating/Cooling Supply) t csidential"Water Supply(single) ft- ft. in.
1ndustrial/Commercial Residential Water Supply(shared) 28 GROUT I '
Irrigation RRQhi I iro MATERUL EMPLACEMENT on&AM
Non-Water Supply Well: ft v, ft, U ��
Monitoring ecove
r7` ft. ft
Injection Well:
A uifer-Rechar a fi I Ft
� 9 g �GroundwaterRemediation
Aquifer Storage and Recovery [�Salini Bawer �'SANDIGRAVELIDACK(ifa licabte
P.1' tY FROM 1TO MATERIAL. EMPLACE111EIQTMETROt
Aquifer Test OStormwaterDminage It.
ft.
Experimental Technology OSubsideuce Control ft I ft
r Geothermal(ClosedLoop) OTr-acer 20.DRULINGLOG(attachaddifionatsheetsifnecessa"
Geothermal(Heating/Cooling Return) °— Other[explain under#21 Remarlrs} &ROm To n>SCRIPTION(calor.ham ms sn'jif—Ir ry G=rrin slze-
6 ft t 3 ae�k, 1
4.Date Welt(s)Completed: I -A- Well M# ft it ry
Sa.Well.Location: Lid
ft (J5 ft aIWA tflk—
vlf6r'�( G, ft- ' SO OSY ft' , e--
Facili /OwnerNamc 6 ft. VS'ft.
tY Facility TD#[;rapplicable) I
2z,-' w
� N� uf�s � �r<ssy Grp ft I ft.
Physical Address,City,and Zip A. I ft ya
"21.RERrIARKS -
_ County ParcelIdenttaeationNo.Q?M) MAR 0 2023
5b.Latitude and longitude in degrees/minntes/seconds or decimal degrees: I
(iftvcn field,gA¢laUlang is sufficient} 22.Certifeatip l>v"Qi 3--1I=
N W �
6.Is(are)the well(s) ermanent or ©ITemporary SiguattauofCerifiedlVeII 9611tractor Date
By signing IMAM I hereby certify that the wells)ivar(were)constructed is acc
7.Is this a repair to an existing well: Dyes or o isWt 1S2 NCAC 42C.0100 or 1SANCAC 02C.0200 Well Consinrclion Standards or,
If this is a repair,fill out known ivell consnuetion information and explain the manure ofthe cqpy odds reco7 d has beeaprovided to the welt mvner.
repair under 01 remarks section or on the back ofthisform.
23.Site diagra or additional well details:
III S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use tie back of this page to.provide additional well site details
construction,only i GW-1 is needed. Indicate TOTAL NUMBER of wells dulled. construction deltails. You may also attach additional gages ifnecessary,
SUBMITTAL(INSTRUCTIONS
f 9.Total well depth below land surface: 229 - (ft) 24a.For All Wells: Submit this form within 0
For multiple wellslistall depths ifdijjerent(ecample-3@200'and2@100) 3 days of completion
construction to he following:
IQ.Static water level below tog of casing: (ft) Division ofWater Resources,Information ProcessingUni
j i I -Ijxater level is above casing,use"-r-^ 617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.
L 24b.For Iniec'on Wells: In addition to sending the form-to the address
.12.Well construction method- t, fzLr� above,also sul)ttt"mit"one copy of this form within 30 days of completion
C auger,rotary,cable,drrectpusN etc.) constructiont0 We following:
t.e.au
II FOR WATER SUPPLY WELLS OINLY: Division of WaterResources,Underground Trajection Control Progr
1536 Mail Service Center,Raleigh,NC 27699-1636
i 13a.Yield(gpm) 7 Method of test-
Mc 24c,For Water SLDPIV&Infection Wells: In addition to sending the:the address(es) above, also submit one copy of this form within 30 t
13b.Disinfection type: �"� Amount: completion of�ve11 construction to the county health department of the
where construe i!