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GW1-2023-02125_Well Construction - GW1_20230303
LL CONSTRUCTION RECORD(GW-I) For Internal Use Only: i1.Well Contractor Information: (--.• ��ct:�P�t 14.WATERZONES Well Contractor Name I ERO,I I TODESCRrn 1TOly L��3 Ft � Ft NC Well Contr@ctorCettificationNumber 7 ,p�rERCWSING for multi-cased wells OI2LTiVEtt ifa llcable t5 W r t J PROM TO - DIAMETER THICKNESS MATERIAL I t 1 fE: I in U� ComoanyName 16.R NER CtLSING OR TUBING( therm it ciosed-lon ) 2.Well Construction Pemdt#:_ '7�?Cef 7Lf. FROM TO I DL"M1ER I TMCKNEss I aIn'1-ERlar. Listall applicable feell construction penttirs(i.a UIC.Count};Stag Variance etcJ % I ft. in. 3.Well Use(chesirweIl ase): ft: fL WaterSupply Well: V.SCREEN I' i I' FROM TO I DIAMETER I SLOTS= I TIHMMESS I MATE I _ Agricultural VIKcsidc., MUM- ' aUPublic ft. I fL in. f' Geothermal(Heating/Cooling Supply) tial•Water Supply(single) I fw in Industrial/Commerciai DResidential Water Supply(shared) LS GROAT I-!- h dgation FROM to A 41SPSAL EMPLACEhIEN17 MErHOD&Ant t Non-Water Supply Well: '. ® fk 19 = C ft. �(` rQvf -'Monitoring ORecovery Injection Well: i -.Aquifer Recharge MGroundwaterRemediation = G Aquifer Storage and Recovery E3Salinity Barrier19.,SAND/GRAVELPACKM.i Reableier FROM I TO MATERIAL- I EMPLACEMENT METH01: Aquifer Test OStonnwaterDrainage ft I ft. I Expedmental Technology [ISubsidence Control f'- I fL s~ Geothermal Closed Loop )p) Tracer 20.DRfI:LINGLOG(attaeh additional sheets itnecessa Geothermal eating/CoolingRetum) --Other(explaiuunder#21Remarks) kxoM TO nEpSrC�RIPi[ON(cpot�or,Iraraorss soiUrocbeve--min foe. � 4.Date Well(s)Completed: —(C .-Well ID# ft, � y it. C-r eti"-ke SS%Well.Locyation: n�rrft. ft. CAP=u'i•r` (' I iG)1"�1 Facllitq/0wncr i�Iamc �e Facility Off(,ifaapppiicable) ft I ft k-• � �~ r..� .; „ �1 Physical Addms,City,and Zip R: I ft. MAR r 3 M.REMARKS County Parcel Identification No.(PIN) .J*271 r"t` "�_-•�""�"",. f5b.Latitude and longitude in degreesImInutestseconds or decimal degrees: (ifwell field,Alattlongissufficient) ZZ.Certifcalo'. ` N W � j 6.1s(are)the wells) ermanent or EITemporary Signature of Cer ifiedWell tractor Date By signing rhisj brm,I hereby certify that the isell(s)spas(were)constructed In acc 7.Is this a repair to an existingwell: Dyes or ivith ISANCACI02C.0100 or)Sit NC✓tC 02C.0100 Well Construction Standards or. If this is a repair,fill out btaum well construeliarr information and explain the nature of the copy.of this record'has beenprovided to the welt owner. repairunder#2lrrntarks section oron the back ofthisform. 23.Site diagn m or additional well details: 3.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use ha back of this page to provide additional well site details construction,only I GW 1 is needed. Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages ifnecessary. is drilled' SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: 24a,For All 6.11s: Submit this fomt within 30 days of completion 1 For multiple svells list all depths ifd different(arample-3@200"arid 2 t@I00) f construction td the following: _ 10.Static water level below top of casing: �'V , (fL) Division of Water Resources,Information Processing UEat, If isater level is above casing,use" I517 Mail Service Center,Raleigh,NC 27699-1617 {" 11.Borehole diameter: �` (in.) ;, ; • "" '•24b.For Ini Ilion Wells: In addition in sending the form-to the address € ©� above;also str)tmit one copy of this form within 30 days of completion f .12.Well construction method: L r �y r construction to the following: 1 CLe.auger,rotary,cable,directpush,etc.) Division of Water Resources,Underground Injection Control Progr j FOR WATER SUPPLY WELTS ONLY: 4 636 Mail Service Center,Raleigh,NC 27699-1636 13a.Yield(gpm)_ _ ' Method of test: 24c.For Water.:Supply&Injection Wells: In addition to sending the: F�414 the addresses above, also submit one copy of this form within 30 c 13b.Disinfection type: G 6Amount: completion of well construction to-the county health department of the i where cousfru Ited. fI