GW1-2023-02846_Well Construction - GW1_20230418

WELL CONSTRUCTION RECORD(GW 11 For 1ttternat Use Only.
1.Weld Contractorinformation:
14.WATER ZONES
wellco orwame ]PROM I To 1 DESCRIEMON
IL
1t. rL
AIC WeII COntrallorCertifiaitionNumber
15.OUTER CASING(formNti-cased averts)OR LINER if o lie le)
r 1YlC: . FROM Ft
no ma3t rxtCKNESS sin
Company Name • a
�_ a at W.-fa
'y,r r 16 CASING OR TIIBING thermal das>sd-loo )
2.Well Construction Permit#: ✓ t g �?l� FROM 70 D1A�rER Tmm ss Mr,�rEtttaL
List all applicable well aomhndian pmvb(te.UIC;CoutV.Stare lrarimrce.etc) IL IL
3.Well Use(check:well use): iL IL in
Water Supply Well: 17.SCREEN W
FROMTO MIUMAMMM SLOTSIZE M R EVFSS 3LITEBIAL OAgricnitorai OMunidpaUPublic �
R in,
OGcothinaial(Heating/Cooling Supply) 'ytesidcntial Water Supply(single) tt tt in
❑IndustrialfCommekeial QResidential water Supply(shared) I&GROAT
Obligation OWells>10'0-000GPD FRQMt To ML1TERiAL EMPLACEM T. D&AMiOtLVr
Non-Water Supply Well: C'1 is _ IL
olvloniftubg - - ORecotlxy 3 b' a� R' uv4� 2
Injection Well:
OA uifer Recharge IL fL
9 �c OGmundwater Rcmediation
OAquifer Storage and Recovery OSalin Barrier 19 SANDIGMAIM PACK(ifs oblc
F80Mt 7ti 31A1ERiAI, &KPI.ACIs�1E�TfMlilTHOD
OAquiferTest O nag
StornmaterDrat e IL ft. 1'
- . .. .....
OFapaimentalTechnoloey - OSubsideam-Contfol & It
OGcothermai(Closed Loop) OTracer 211L.DRILLING LOG attach additional sheets r7
OGeoti►eimal(Hating/CaolingRemm) OOther FROM7 TO :, -..-DESCRIMO�T(corm;kitdntsssawre �amsae,ete)
e�lairi under g2l Remarks); £ _ ;4
4 Date Well(sj Completed 3 We11 ID# 3 7 t�", R it. /�
Sa Weu Location -- . ...._. .. ._.._ - , tt: 'm =.Lt' �G L
CRt.. L..,,. v(,°� Iv1G.. f� n rt l� tt.. r ?✓1
Facititp/Oivn�Name 1�irtyroc.(ifwliable
-� � l l'C
�iG1 SF,e motl" G: j7 -ram tr�
Physical Address tCiLy.and Zip R R y ti inn
2L REItIARK3 n t r ?I
�:, • 181•��43`Z�
CO�y Parcel Identification No.(PIN
36 Latitude and longitude in degnmstmmntedseconds or deamal degrees:
(if arelt field.and tadlaug isst�cient) ,.. . .. ��; rs. r, �v�+;�.:s•� i' r - ........:... .
t j a
6_is(are)the well(s): ermaneat or Oemlorary '� Sigoauac of •enifi Vell Conuacw :-. 3 ..: •..
,:..,
Crsigningihisform Iherebvicertifi>thgt the urll(s)innsOvere)constructedinaccordanceeith
7.Is this a repair to an existing well: OYes "or lSA MCAC 02C_0100 or 15,111 GIC 02C A200 Fell Comiruction Staiidards'arid that 6 edliv
FlUr is repair.frlt out Drown uW1 consvverian information and explain the uolure of he ofddsrecord has been provided to the.jTfi owner
repair under it2l rswasEssertion or on the back oftlas forne
23.Site diagram'or'additional well details-
8-For GeopropelDPr,or Qased-Loop Geothermal Weft having the same You rnay.use th6tack of this page to provide additional well consnuction.info-
66, ction,only k G9V 1 is needed. Indicate TOTAL-NUMBER of aielis (�-�Over in Rwm is Boggy You may alp attach additional pages if nary,
24.SUBAUTTAL INSTRUC170NS
9 Total well depth below land surface: A U 7
_..
For mn(tip/e ar11s list dl depths ifdrfferent(ecample 3 r 200'and 2(g1003 Submit GW-1 tvithiu30 flays of tveQ compleQon per the Maiving:
lo-Static water level below top of casing- :a O � �: - Original fob -Division of Water Resoutees (DWR),.
For All Wells+ O ginal to
lfureter level i abb�r awing rue"+- nforutatio k Pmp e g Unit 1617 MSC•Raleigh,NC Z7699L1617-
i 246 For'Inlechon Wells.Copy to,I)WR,Underground Injection"Coiibol(IUC)
Program,;1636 MSC Raleigh,NC 27699 k 636
�nl pp
_ 76 ;
12 Well aonstrac[ion method: 9L 24c.For Water and Open-Loop Gmthermal Return Wells;Copy to the.,
(+e augeS"ikcabte,cheer paste.eta)
_.._ ._. �� environmental health department of...the county where installed
FOR WATER SUPPLY WELLS ONLY _:_
_,. 24d_For Water Wdls arudncmQ over 100,00o GPD-Copy to DWR CCPCUA
-- t �� l 'Perttilt Pto gtaiq 16k 1 MSC;Ralei NC 27699 1611 .:
13a.Yield(gpun) I Ci hletitOd of test= fi tom. _
_. .
13b.DWwfectionlype: L ^t Amount; Q 0_17
_
fotmGW-i._ NanliCaiolinaDepanmentofEnvuon�matQuality=Dnlsionof,WateiRaoimns Rr�viox166?Ors