GW1-2023-02127_Well Construction - GW1_20230303

-WELL CONSTRUCTION RECORD(ram 1) For Interval'Use Only:
1.Well Contractor
Information:
14W} t1OEAIL —/,,Apr . tTEzNS
Well Contractor Name FROM I T.O ) DESCRIPTION
1 90 o / ft
ft.
NC Weil Contractor Certification.Number 1
'A 15.OITCER CASING for u,ulti-cased wells ORL1=I R,f n licable
Dob Is bid o�,,lllNlyt FROM ITQ DIAMETER THICKNESS MATERIAL,
Company Name"
IL
I It in
�/ 16.1A`NER CASING ORTflSING(eothemaldosed-loo )
2.Well Construction Permit#: /iJ (� FROAr 11 TO DrAMFrFM I TffiCKNESS
Lirtall applicable tvell constructlonpetmits(i.e.UIG Count};State,Variance.etc.) I ft in.
!' 3.W4 ff Use(chesltwelfuse): ft 11 ft. ia.
WaterSupA Well: 17.SCREENI
FROM TO DIAMETER SLOTSIZE TMCKNTSS RSATER
{ I Agricultural �MunicipaYNblic ft. I ft in.
V Geothermal(I3cating/CoolingSuppIy) Ofmidential-WaterSupply(single) fE: in.
Indastrial/Commercial DResidential Water Supply(shared) 18:GROUT I
Irrigation FROM I TO MATERIAL EMPLACEMENT MEMOD&AN]
Non--gaWater Supply Well: £t I ,2_0 ft.
I _Monitoring DRecovery ft. I it
I-Geothermal
jection Well:
ft I ft
k Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery DSalini Barrier �SANDIGRAVEL PACK-r€a -licable
ty RROM TO MATERIAL. EMPLACEMENT METHQL
Aquifer Test OStonuwater Drainage I ft
j Experimental Technology OSubsidence Control ft IftGeothermal(Closed Loop) Tracer 20 DRIl�LINGLOG(attach additional sheets ifnecessarvFROM ITO DESCRIPTION(rnior.hardnemsait/rackt e- rdnatze.(Heating/CooImgRetum) f— pther(e Iainundr#2l Remarks} it. I p ft l/_r+���o ,'c�4f� ✓� J'C
4.Date Well(s)Completed: L yi_96X ✓ 1 ✓,t✓ L dk/
5a.WeRLocation: ft I ft.
it I ft
FaciII /OcvncrNamc ft _it
tS' FacilitylD#�fapplicable) i_ - •^ :"` a�:k
S� G-i/77 , '
PhysicalAddress,City,and zip ft I its R ,�
'4 /'e 01345050 21.RENtAIM W
- County FatcelIdentificationNo.(PIN) I In""~ "'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I V
{if wcll field,yt-]at/long is sulficicut} 1
22.Certifcatio
373 063 W 1
6.Is(are)the wells)Q ermsnent or E3Temporary
Signature of Cei',ed.Well tractor Date
By signing this I orm,I hereby certlJy that the ttTll(y was(were)constructed in acc
7.Is this a repair to an existing well: OYas or No ivitlt ISrl NCA0 01C.0100 or ISA NCAC 02C.0200 tlrell Consintction Standards or.
If this is a repair,flit out know?well consinxilon information and explain the nature ofthe Copy ofthis record has beenprovided to the ivetl oumer.
repair Tinder 1121 remarks section or on the back ofthis form.
f 23.Site diagrl m or additional well details:
You may use the back of this page to provide additional well site details
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
jconstruction,only 1 GW 1 is needed- Indicate TOTAL NUMBER ofwells construction dletails.You may also attach additional pages ifnecessary.
1 drilled: SiIBMITTAL�INSTRUCTIONS
9.Total well depth below landsurface:
( ) 249. For All I Wells: Submit this foam within 30 days of completion
For multiple tivellsluta/l depths ifdpererrt(ecample-3@200'and2(e,�rI00) consttnctiOnti the following:
I
10.Static water level below top of casing: 2SD (ft) Division of Water Resources Information Pin IJni
fJlsater level is above casing,rise �" ° racess g t,
�1617 Mail Service Center,Raleigh,NYC 27699-1617
f 11.Borehole diameter:
1 gym') 24b.For Infection Wells: In addition to sending the form-to the address
above,also submit.one copy of this form within 30 days of completion
12.Well construction method:_ �,Y t'b rav y construction to the folIowin.�
I ! (i.e.auge4 rotary,cable,dit-t push,etc-3
FOR WATER SUPPLY WELLS ONLY-
Division otWater Resources,l7nderground Injection Control Progr
1 �1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) A(f Method of test: •/ 24c.For Water.Supply&Infection Wells: In addition to sending the:
the addresses? above, also submit one copy of this form within. 30 t
131I.Disinfection type: Amount: �b�7— completion Of well construction to the county health department of the
where constructed.