GW1-2023-02126_Well Construction - GW1_20230303

WELLCONSTRUCTION RECORD ��1 ForinteMall I -
j — IUse Only
1.Well Contractor Information:
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Well ContractorName FROM FO I I DESCREMON
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NCWe7lContra �
ctorCeaatianNumber
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15.OUTER CASl1dG form M—ed woUsl ORITM-R Ln IIca6Ie
k �ye✓ �� G! ��!t I j��J� MOM TQ• R AMETM THICiffiPSS 1hL1TERTAi.
Company Name
16.11 R ORTQSING eaWermalcl ed-loo ) f
2.Well ConstruWonPem it##: 37oq 77 FROM�f7�ft.
DfAhj T1�1C1INESs I 93ATERraT.
I List all applicable*tied cOMMotron permits(I.e'.MC Count';Stare,yar tce,ePtc) in.
f 3.well use(cisedrWerruse): % I ft ;n I
Water-Sugply Well: 17.SCPXW -1
PRO�ft- T�
MWETER SLOTsl2C T9IMNES5 MATER
Agricultural �M icipal/l'ablic in.
Geothermal(Heating/Cooling Supply) - Mential Water Supply(single) ft I fk in.
v rudustrial/Commercial OResidmlial hater Supply(sbaied) I&G--'UT I
adgatian FROX 0
n MATERML F.MPL10En1Eit'rMETROD&AM
[Aquifer
Water Supply Well: G &
l
nitoring ORecoveryReebarge OGroundwMi:Remediation %
ifer Storage and Recovery Salinity BoaterwCur I TO ' MATMALifer Test E3Sto>mwater Drain age ff.
FxpedmentdTechnology OSubsideuceControl ft &
t Geothermal(Closed Leop) OTncer 20 G(attach additianal sheets ifnecessarTO
rl
Geothermal(1-Ieating/Coolin —gRetum) Other(explain urrder921 Remarks o
— DESCRtPr[oH fcolor,7,s�uess soarrortce, o"ten s,ze
4.Date Wells)Completed:JIL21 • j'Z Wa l®# 77 fr. fG(ll
�i Sa.Well-1+oration: ft i ft:
f ffnn t' IGOSPv ft I ft.
a
EacftiWOwnorNI ama FacititglD#[fapplica6le)
sloe Pack Rc Jf Pe'Soh Q/G, ZcS6Erj f*
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i'fi "cal Address,City,and Zip ft. I , -ft. I—
rt-- r,...
h C�9 Z3-9a1 z3.RtttlA2txs1 ; : '�
County . PareelIdenfiacationldo.(MO I A g.
I5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwalt6efd,wfk. tnoogissu�Scient) liiisi• ;' � O 2S.Certifieatio +/j/�Jr/}J�//]
3G-Li 3 7�t _ �I: �tG 71G W
-72.1
6.Is(are)thewell(s) Permanent or QlTemgorary sigoaamofCerri -
lfie.Well � ace
By siganrg this tots,I hereby certify ffmi fire ueII(s)was(were)corutrarled in acc
7.Is this a repair to an esistingwell: 7€es or 1V0 id%15t1 NCAC 02C.0100 or ISANCAC 02C-0200 Orell Consintellon Standards ar
Iflhuisarepair,fdtmmbrawnivellconsirwiiminformationaadesplainMenarareof-die CoPPofthrs hashamprovidedtatheitel!owner.
repair tinder�01 remarks section or on ilia back ofthisfarrrc I .
23.Site diagram or additional well details:
S.For GeoprobeMPT or Closed-Loup Geothermal Wells having the some You may use tIe back of this page to provide additional well site details
! construction,only i OW-1 is needed. Indicate TOTALNUMBER o€wells construction details.You may also attach additional pages i€necessary. -
drilled: -7 r, SUBMITTAL INSTRUCHONS
I9-Total well depth below land surface: stun` ( ) ?Aa.For All Wells; Submit this forin within 30 days of completion
Formaltiplervrd&&talldepthsifdlfferent(erample-3(200'and2@1003 constisotlontO`flefollOWing:
10.Sfafiewater level below top of casing: (ft) D3vt's�on of ZYater Resources Information Proeessia {7ni`
I Jfnvter level is above casing rue (ft)
Msii Service Center,Raleigh,NC 27699-1617 �
11.Borehole diameter:�l�S
(in.) 24b.For lnieetion Wells: In addition t0 sending the form.to the address
/� above,also subm n.
it-one copy of this form within 30 days of completio
12.WeRtonstruciion method-Air- Ct r cmostractionto tTtefoliowina
i (Le.auge4rotary,cable,daeetpusk etc)
Division.of Water Resources,Und ound
ERSUPPLI'WRLLSONLY: � ezW IgjectionControlProgr
FOR WAT
1636 Mail Service Center,Raleigh,NC 27699 1.636
132.Meld(gpm) Meth od of test:-Mz b.t 9 f� 24c.For tea Snnniv&Injection Wells: In addition to sending the:
oZ
the address(es)Iabovc, also submit one copy of this form within 30 c
"b.b.Disinfection Type: Amount: completion of Well.construction to the county health department of the
where consttuct�d.`
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