GW1-2023-02117_Well Construction - GW1_20230303

-WELL C _18TRueno I RFC(3RD f Wit Forinternal Use only: -
1
j I.Well Contractor Illfarmation: i
1 �t�r�✓1Q ` ]A WATER
i Well ConaactorName 1ROM to, 1 . DESCRD 0-xq
NC1Ye0 CantractvrCerhf-tcationNtuabet
2zafL azs it: f M
15 017£SIt CA57NG t ar multi-=id wells*1 ORLITIMU if n iicahIe
(� l� DEAhIL•'TER TH MESS KATERIAL
Company Nmea it: j in -2I c
^/'/ L6,RWkCAMNGORTOSING eatherm2tdosed-1"ool
I 2.Well Construction Permit: . DR
;0 U l kxo �o i DrAl� TalclavEss MATERIAL
jj Lfstalt aopGcable wallconstMWUn penmrs(%e:UIG Cowin;Srare Variance etc.) h• I ft.
I'I 3.Well Use(chesltwelCuse): ft. I tt in.
(,# Water-Supply WeR, 17.3 1 I
} ._•Agricultural tatpaUPubiiC FROM. TO DLiMETER SLOT SIZE TffiCSQNFSS MATER
ft in
Geothermal CReating/CoolingSupply) Erkcsidentia Water Supply(single) fa ft J in.
ti rndnstnal(Cammerlal DResiftntial Water Supply sbared
IlQgat[on FROM TtT' I MATERIAL EMPLACEME1TrM11ErFiOD&Altl
1 Non-Water Supply Well: 0 a- 70 Dr �J!
j MonitagngO
Recovery it. I f'
Nection Well: fr.
AguiferRecbarge ECaouridwaterRemediation I fft.__ I
]9 SAND/GRAYEI�
_Aquifer Storage and Recovery E3Salinity Baw PAC�tifs Ctcableer FROM To i 7ATERIAL I EMPLACIIti[rIT n-IETIrot
Aquifer Test' � •�i E3StormwaterDrdsnage ft. I £t. I� '
Experimental Technology 0subsidence Control
Geothermal(Closed Loop) Tzacer 20.1)RILLItyGLOG{aftaefi additional sheets irnecessa
Geothermal(Heating/CoolmgRetnm) . Olher(e Iainvnder 21 Remarks) O UFSC IPTIOPI[color,Hardness sorllrocktyne erria s¢e
4.Date Wel(s)Completed:�-�`/-2 3 Wei Wk 52-
it I it:' Sa.�YellLoration: I
nald Cn•�
Facility/OcmecName FaciHtyIDf(ifapplicable) R I 'f
Zq9 I'Ve-C Wt•115 V t d.l
PWIcalAddrws,City,and 2-1p ft I it
2?.$ naattxc I
cowti PatcelIden0catiomNo.g?R
5b.Latitude and longitude in degrees(minates/seconds or decimal degrees:
j ff wclr 6utd,VllLkt tang is cufficicM) I
22.Certiffeati
.K 23"� �l , K-71%d W
- -ZS-23
6.ls(are)the well(s} ermanent or EITemporary SrpratumafCertifiedlVeILGAEwwr Date
B sr rn rhrs oI
Y 8n rm t hereb cerG [hat t/ie ar�Rr ivas vere 1; .f F r cansrnrcted r- fY (� ( n ace
7.7Gstdtfsarepaix:uanesast�.ngtiveTl. �.7�PS or n+r1li15tLNCtfCI)2C.0100or?5itNCriCO2C.0200 Drell ConstnrctlonStnndarrisnr,
I this.isarenalrfdlourlimwaiveilconstruenonitformotioomrdespiViarhenantregfilre -pPOfthIsrP�has b amp r•Ivldedtot/rejcelFmmer-
repair under�21 retuarks section or on the back ofthasfarm
23.Site diagra I or additional well detais:
S.For Geoprobe/DPT or Closed-hoop Geothermal Wells having the same YOU may use tl a back of this page to provide additional well site details
construction,only 1 OW-1 is needed- Indicate TOTALNUMBER ofwells construction details.You may also attach additionalpages ifnecessary,
drilled: rp S_[3B]YiCETAI. III�75TR1TCTfORTS
9-Total well depth below land surface: 3�5 j
( ) 24a.For Alt Wells; Submit this form within 30 days of completion FormatlfpfetvelLrlutaiidepthsifdiffererrt(ecarapie-3(a)200'andF(a�I00) constmctionio the following:
10.Sfnfiewater level below top of casing: YL) Ill ''s�Ion of 4Yatetr Resources it,Information Processing Unit,Ijlwter tenet is above casing•use"'" 1 R7 AMI S"ce Center,Raleigh,NC 27699-1617
Y 1.Borehole dfamety: 24b.For Inieeh'on Wells: ?n addition to sending the form-to the address
12_Well eonstraction method:L y above,also submmit.one copy O£this form within 30 days of completion
fze.-gm-tam cable,dimetposb,etc) constractioato tbefoliOwin�
Divisionof,'TaterReso ces Under ouad Controlprogr
J FOR WATER SUPPLY WELLS 0;7LY: 1636 Iblall Service Center,Raleigh,NC 276991636
13a.Vield(gpm) Method of test: 24c.For Wate�SnDpIv IIniection Wells: In addition to sending the:
the address(es) ovc, also submit one copy of this form within 30 c
i 13b.Disinfection type: Amount completion of Vvqzeu construction to the coup,y health
p where constimetd d. deparnnettt of the
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