GW1--03176_Well Construction - GW1_20230505

7
WELL CONSTRUCTION RECORD(G -I For Internal Use Only: 1-4-
1.Well Contractor Information:
r
at�M\St'S(] 1\ C� 14.WA ZOOS
1
1Vc11Contractor h`amc 1IDM TO ( DESQtWFlOfi
lry�a' IL 4,ia It. 1No� )‘ow
�Dq 3— Pt- ..
NC Well Contractor Certification Number 1 � �, G�'S a. �l��
P (' 1 y-�+ t3.OITFER CA9IlVG(ibrmUItheaSed wells)ORL!NER Of us . •j
A ` ,'�� �`_'vk `it.S 1 A ` c - FROM T�1 DIAMETER THICE�tESF RTATrRTAT.
• �✓ ft, ft. in.
Company Name 16.I10iNERMEA1 ORTQBING(geothermal closed loop) -
2.Welt Cent notion Permit if: a),a 3—0 0 I _FROM _ TO I DIAMETER THICKNESS MATERIAL
Lilt all applicable well construction permits(i.e.FIIC.County.date,Variance.exc.) 0 ft. 33 It. in. cCl Si raA
3.Well Use(chec6 welt use): in- Ifre t.401.l,S _ d r i I I I
Water Supply Well: 17.BCSIiEPI•
FROM r TO I DIAMETER SLOTSIZR TRICIOIESs ALITERTAL
M Agricultural Elorcipal/Public ft. ft. in.
*Geothermal a leating/Cooling Supply) Residential Water Supply(single) ft, ft_ in_
MlIndustrinl/Commeleiat DResidential Water Supply(abased) faou ,.-..,�
I Uri Om . FROM TO- _MATERIAL EMS Am1mTMEoHOD&AMOUNT
Non Water Supply Well: rt. ft.
II Monitoring ioRecovcry rt. - ft.
Injection Well:
*Aquifer Recharge EIGroundwaterRcmcdiation it.
t•quiferStorage and Recovery SalinI Sairicr 2g SA GRAVELPA�(W� ble).
FROM TO Ara FRLIL MlIPL.ACMIENTrfET IOD
it AquiferTest l5tormwaterDrainage ft.
if Experimental Technology °Subsidence Control ft. ft.
It exothermal(Closed Loop) Onager 29.DRILLDIGLO4fattaeltadditionttishesttatfnesessasya - .
x Geothermal(Heating/Cooling Return) flOther(explain under#2I Remark s) FROM TO DgsCIUFTfolufmlm:tratan�,wurroctit3De.atatn,tu,art _
NDit; 641'rft. AroAi
4.Date'Well(s)Completed; 4-Ate-a 3 Well IDit tt. ft. • •
3a.Well Location; • ft.+ . b
—
F1 i-a�:e.R M��sun gy ft. ft. , N, ?_IL:.�.a�V ..^. ..�
FncllitylOwnetNarpe '' S
FasilitylMe(ifapplcable)
5 t�. cc04 a U -. r� M u Y ?(1
�
,2 .evcy Celli_ ed. A sl tv:I i, lac .28go y ft: ft.
`� t
Physical Address,City,and Zip • ft R• 1(lifiirit'_�:•^., 1 �'I• '��`r� :i�
�i.EEMARIIS �*X171.-h
�r®mbe 431G 13349`tT-go04500
County Parcel reentilkadse No.(PIN)
3b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t
(tP well field,one latnong is sufficient) 22.Certification:
35 391 38".gIIS4V 'lN 72.(9.29' 2.),1.SIU13 /' W
•
6.1s(ore)the well(s) ermanent or DT pnrary03
igtmture of Certified Well onrraclar Dale
By s(glthrg air:arm,f hereby certfy that the veils)was(were;coastnlcler!in accordance
7.Is this a repair to an existing well: es or �INo with I5ANCAC 02C.0I00 or ISANCAC 02C.0200 Well Construction Standards and that a
If this it a repair.Jilt our known well construction information and ecplofa the nature ofthe cans of thisrecord has been provided to Ma well owner-
repair under 021 remarks-section or onthe hack ofthisform. 23.Site dia
gram or additional.well details:
B.For CeoprobelDPT or Closed-Loop Geothermal Wells having rho ensue YOU may use the buck of this Etna to provide ndditianal welt site details or well
constructton,only 1 OW-I is needed.Indicnto TOTAL.NUMBER ofwells �� erica details.You may also atrnehaddieionnl pages iFaeeesaasy,
drilled: stt6RNTTTTA_LitNRrRucnsa g
9.Total well depth below land surface: CO Lis-- (ft) 24a.For All Wells Submit this form within 30 days of completion of well
For multiple welts list all depths ifdifferent(example 3@200'and.2ali00) construction to the following:
le.Static venter level below top of casing: GX qt7 (ft.) Division of Water Resources Information ProcessingUnit
If traler level is above rasing,Buse"÷ �,r 1617 Malt Service Center,Raleigh,NC 2769 . 7
11.Boretiole diameter: to• J (In.) 2db.j+or In1eetinn Waits: In addition to sending the form to the address in 24a
13.Well construction method: et,i-4 above,also submit nne copy of this form within 30 days of completion of well
(ie.auge,rotary,cabin,dhccrpush,ctc) CAnsIrilChDIIIQt$C following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 16361%fall Sarsilee Center,Raleigh,NC 276994636
13a,Yield Om) 1 b Method of test: gia I. CCM inAut.24e.For Water Snunly&Injection Wells: In addition to sending the form to
the address(es) above,also submit one copy of this form within 3D days of
13h.Disinfection type: Ch1f114rs.9.. Amounti 6 'k b S completion of well construction to the county health department of the county
wham constructed.