GW1--03631_Well Construction - GW1_20230526

IVER LL.CONSTRUCTION RE,CORD(M-1). For Internal Use Otily:
1.We?l Contractor Infformnation: I
Jbr1 (�elT`ei` 1.1.WATERZONES
Well Cont ractorName R03t 70 DESCR1PTtOti
tic wC q07 Cl -
NC Well Contractor Certification Numlter
Il�tts ft t27 fL Gr s if jGr n
-- 11 t I �n}/ -I5.OUTER MING(for mulli-cased,sdls) R LL\TER(if n iivable)
lJ ,,wee - [�l L�- �Gl LJ/r'6mei FROM TO D1,iltETER MCIIMSS 3L-tTERL1L
Company Natn: -
ft. fL in.
m��O ' Z 3 M.INNER CLING OR 7 UBING(geothermal closed-loop)
2.Well Construction Permit n: � _ FROat To DMITErex Tutct:.\Fss NITTERUL
List all applicable tell eonsimction permits(i.e.U1C.Cottnrc Starr,t ariancY,etc.) R• n, in.
3.Well Use(check iseil use): rL ft. in.
N ater Supply'Veil: 17.SCREEN
E7tU3f GDolinQ Supply) TO MANYPTER 3LOTS1?.E TinCHNESS -MATERIM.
-❑A�-icultural ❑iYlirnicipa!/Public ��--� fr. �/� ft. 1/ in_
❑Geothermal(Heativ� DResidential tiVater Supply(single) 2 L G I V
` ft. rL in.
❑Industrial/Commercial ❑Residential Rater Supply(shared)
IS.GROUT
llrrigation 111"ClIs>100.000 GPD FILM i To SLITERLIL E1tPL-tCE}iE\7}9ETfiOD i �tou-�T
Non-Water Supply Well:�4onitoring '` `:� ,$ �l(eWit
I rills/-e
. , .
Injection Well: ;�310rN(>= /
Ut"t;
' ,,+m.� fL ft.
QAquifer Recharge I,AA ��({ itOz?1PGrotntdamter Remediation
QAquifer Storage and Ic ``c ❑5a''ni1•Barrier [9.SAND/GRAVEL-PA (if n.Ducable)
` _ F[tO:II TO I IEliPLACEiti[ES'TiltETIIOD
❑AquifcrTcst �gi�+s,?ri tormivaterDrainage fL 1t/,7 R-
1 MxTerimental Tac2iiitiloeTy r�a�dim c3' ' ❑Subsidence Control
aGeothermal(Closed Loop) ❑Tr2cer 20.DRILLINGLOG(attach additional sheets if necessary) .
(7Geothetmal(HeatinglCooling Return) ❑Other(explain undo-=':R-2 =6 ) I Ol[ TO DFSCRlPTLO\t star:bardcas ioiHraek r•graIn size eta)
1 0,C) n- als fL Q r
4.Date Well(s)Completed -I 2 3 Well Ill'M PC M W 10 S L �t n. 7912 fL C � toe f 8 t o
Sa.Well Location: y s ft. fL
efg 9rS- rt. ll9,,.r
Facilit}'iO:rner\ me Facility lD#(ifapplicable) ft• �z R. (,
n s7
�re5f'hne G ��i M,-.- (eetJ U.0 t z 8 31 S ft /yz n, r
Ph}stcal Address,Cm'.and Zip - y it.
uu n
21..REMARKS
Counh• P :tldentitication,2o.tPiNl - /7 l'�a - 7'Lor c{ Worllt Sr/7
Sb.Latitude and longitude in deo - f 1!(2� r
e grecs1dilnutes/secouds ordecimi il brees
(ifwell field,one lat/lone is suflicicn) .'.i
/ 2-1 �l 6.. / // _.Certification:
' ZN $ W
6.Is(are)the well(s): -#Permanent or ❑Temporary sii�irature fCcrtiticd 11 Contractor Dan
Bpsignin t1is form.I hat.•ar rertif•drat the Ivell(s)war(tree.)carulrre(ed in accor ooce:vith
7.Is this a repair to an existing well: LYes or )tNo IS-•t?TCAC 02C.0100 ar ljs N*C-7C 02C.0200 nc11 Construclion Standards and Ahae m copy fl this is a repair•fill arrr brotrn[Pell Coz:r.-Jc:ian ioli'miallon and erpher r.':e•nat:aY o/rbe ofthir record has beeniv—Ved is the o ell ottner.
repair under 531renttirks section or or-:het �„gfthform is . -
_ 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells same i ou may use the back of this page to provide additional well construction info
construction,only I GIV-?is nz•`ded. Indicate TOTAL`'i MMc??oficells (aad'S=e Ove;in Rema&q 8us).you may also attach additional pages if necessay.
drilled:
�-• '_-t.St SlIMAL INSTRUCTIONS
9.TotaI well depth below land surface:__ 1 J , (fL}
For nlulfiple tells list all depllzs ifdFJerent(e,ample-3r-300'ar2 160 Submit this GVV-I within 30 days of
liceil completion per the following:
10.Static crater level below top of casing y�o 1 � tft W 24a. For All birells: Original form ito!Division of Water Resources (D\\`R),
Ifismer level is above casing.r_se"- ?nful7itati0n Processin_Unit.1617 Q'C,'Raleieh.NC_217699-1617
11.Borehole diameter: 7 (in) 24b.For Injection Wells:Copy to DIYR Underground injection Control(IUC)
Progratn,1616 MSC.Ralci_gh.NC 27699-1636
I2.W'ell construction method: 5d ki iG 24 F �iratcrS I i.e.auger,rotary,cabk�.direct pushi e1c.) aot upPiy and O aen-Loon Geothermal Retnrr iS.'elts Copy to the
county eui7rotimettLL?n.fifth department ar the county where insra?leer
FOR VMA1'F1Z SUPPLY WELLS OitILY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR•CCPCUA
13a.Yield(.,-pm) Method oftest: Permit Pro•—at.1611 1ISC.Ralcieh,NC3 169 9-1 61 1
136.Disinfection type: Amount: