GW1-2023-02134_Well Construction - GW1_20230303

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WELL CONSTRUI CTION RECORD(OW 1) For Internal Use Only_
1.Well Contractor Information
14.w9TER2QNFS
�. WelI Contractor-Name FRODE I EO DESCRTYTION
L�
i IL I fL
NC111ell Contractor Certification Number
j L�.OUTEItG QIIVG for dd-wssed wells ORLINI;R if annumhyea
(y ��+1 f 11��(� IROIVT TIUCTOESS RATERIAL
Company Name f6 ft. G 7v m. !l�
2 , 16.flF'NER Ct15ING ORTFISING f eothermal closed-lon I
} .Well CanAMCtiou Permit#:��1!� _ rxxo,� to DlANEYEP, ,TBTe[nvEss T>iRrai•
List all appGcabletsell consLuc7ionpermrts tie UIGtmt�Co ;Stag Yatiance erg) ft: I ft. in.
3.WeH Use(cheskweH:_Use): R, I ;m
I Water Supply Well: i7.SCR sit
P
ROM DLIMET6R SLOTSJZE THIQINESS MATER
Agricultural. OMunicipali?ublic in
Geothermal(Heating/Cooling Supply) esidential-8�ater Supply(single)
fL Ili . Tndustfial/Colnmercial DResidmtial Water Supply(shared) 18.GROAT in.
bEdgation >rtonz tro MAr>rRrAI: >vTerACElv>Eh~r IltrrstoD&,�
j Non--Water Supply 4YeI1: I ft. t
Monitoring Recove ! ��f
O rY %
Injection Well; ft
- A ferRecbar a ft.
g ft.
19 SAND,(GRAVELPACKTIfa licable Arntifer Storage and Recovery OSalinityBarrier ITRonl I To MATERIAL EMVLAC 1ENTMETHoL
Aquifer Test OStomiwater-Drainage ft. I ff.
Experimental Technology OSubsidence Control ft I ft
Geothermal(Closed Loop) OTracer 20.DRFF.L"INC.LOG(attach additional sheets iinecessa •
Geothermal(HeatinglCoolingRetam) _ Other(expIaia under#21Remarks) FROM To DESCRiFITOlktrnlur,bardoess,soiUmekty r.grains,z%
4.Date Wells Completed:C d-S ��-
() P Well ID# �," ft• �� ir. / .�
r
Sa.Well Lotaiion: ft �S ft
j Facility1 tvnerNi ame Facility ID#(ifapplicabie) L d9tl ft.
Mysical Addtrss,City,and Zip it, r j
County 4 Pan:elIdenHiicatioalQo.(PIN) IMAR , -S 2023
5b.Latitude and longitude in degreestnfmutestseconds or decimal degrees:
Gfwcllffeld,0%lat/tongissufficient) ?r2,Certil'IeatIb °R''' �":''�""t,•.,,°1..,.'.•_;.H.- �••..
11{a e'L�Jv�✓1.7
W t
6.Is(are)the wells)t Fermanent or [3Temporary
signatureofCcrafigdwel(r. tractor Date
j' By signing rhirJorm,I hereby certify that 111E trell(r tvas(were)constructed is acc
7.Is this a repair to an existing well: Dyes or Of% lvidr ISB NCAC 02C.0100 or ISiI NCAC 02C.0200 Well Consinrclion Standards ar.
IVINS.17areoair,fdl out known wellconstnxtionirformation and ecplainthenaturegfihe wpyafthisrecmld hasbeenpravidefftatrrewelloivner_
repair under r21 remarks section or an Me back ofthis form.
23.Site diagra 'or additional well details:
3.For Geoprobe(!?]?T or Closed-Loop Geothermal Wells having the same You.may use the back of this page to provide additional well site details
construction,only 1 GW 1 is needed. Indicate TOTALNUMBER ofwelis constnletion de You may also attach additional pages ifnecessarT
drilled:
G .m SUBMITTALINSTRUCTIONS
9.Total well depth below land surface: /
U (ft) 24a.For All Wells: Submit this f011a within 30 days of completion
Formulliple wells list all depths ffdpereot(Example-3 a@200'and 2Q100�
� constmction to t he following:
10.S�tii water level below fop ofcasing: / ( }
Iftsgter level is above casing,use..s'• DivisJon of�'iraterResourees,Information Processing Unit,
l Al Mail Service Center,Raielgh,NC 27699-1617
1 11.Borehole diameter:
-(in.)
•24b.For Iniec'on Wells: In addition to sending the form-to the address
��pp i �D above;also sullmt one,copy of this form within 30 days of completion
i .12.Well construction method: �t+er r 1 k,(
constructionto the following;
tie.auger,rotary,cable,direetpash,etc.}
FOR WATER SUPPLYWRLTES ONLY: Division of Water Resources,Underground7njection Control Progr
1536 Mail Service Center,Raleigh,NC 276991,636
132.Yield(gpm) ♦' Method of test: Air— 24c.For Wage Supniv&Tniection Wells: In addition to sending
'1 the
11 I's the addresses)Iabove, also submit one copy of this form within 30 1
13b.1}isinfeeiion type: Amoant: completion of Iy v�eff construction to the county health department of the
f
where construct-d.