GW1--03644_Well Construction - GW1_20230526

WELL CONST'RUCT'ION RECORD (Gw-1) For Internal Use Only:
).Well Contractor Information:
e Yt 5 d 14_AVATERZONES
Well Contractor Name -- FROM I TO — '-DESCRIi'T10\
35y (90 q. I I-, S I,- Pftil 5�q 0 1,-B-:0:07"TC well Contraclar Certification Number
,0"
N
i 1 15.OUTER C 1SING(for multi-cased welts)OR LL\ER(ira lieahle)
\ FR031 TO DI.�.11E THICKNESS
5 We �--^i l�lv �►' c' ft oa --
Company Name . t r / l2• ke
16.7NNER CAST '�OR TUBING(;_cothermal closed-loo )
2,lN'eli Construction.Permit?r:_3$ 10 rI j FRo?I qL
IIETER T1nclaEss ar.�TERLv
List all applicable nz 11 constrrtction permits Cz_e WC.County:Sra1C I�ariance.etc) rr• in.
3.Well Use(check well use): It. in.
Water Supply Well: 17.SCREEI•RO\7 :-M.R SLOTSI7E TEIICh'vFS .1LITERIs.1-
❑A`ritultaral ❑rtilunicipaUPnblic tL in.
❑Gcotliennal(Heatin&CoolinQ Supply) 6dResidcntial Water Supply(single)
p_ [t. in
❑Industrial/Commercial - ❑Residential Willer Supply(shared)
IS_GROUT
01ni ation 0Wells>100.000GPD FROM TO 3L•1,TERL•1L ENIPL1CF_%M'%-r.'%I IOD&'L%IOLtiT
Non-Water Supply Well: O fr. � ft. � � t
1� G I
LJLlonitoring ❑Recovery �pft_ fr_
injection Well:
CL ft.
❑rlquifcr Recharge ❑GroundyraYcr Rcnrcdiation
❑rlquifer Storage and Recovery ❑Salini Barrier 19_SAND/GRAVEL PACK(iCa plicable) —
ty I110\1 TO MATIR ML E\I1?LACEMF_Vr3IETHOD
❑Aquifer Test ❑Stonra%ralerDrainagc
❑Experimental Technology ❑Subsidence Control
❑Gcotherrnal(Closed I_Dop) ❑Tracer 21L DRILLING LOG attach additional sheets irneeessary)
❑Geothermal(Heating/Cooling Return), UOdler(explain under 4'21 Remarks) FROM TO DESCRIPTION'ieolar,hardness,sail/rock type-mhtn sac,ere)
4-Hate Well(s)Com feted=,5 �'-t4 =;to X-3 j tt- 1 G rt- owe v�.Ae_
aa.-Well Location; .,
6 fr.
� �` � .l c @ L ©G�
Facility/lhvnerNamc, Facility iDY(ifapplimble) ft.•: tt:
13 J ctfrv. ILI -�
Physical Address,City,and Zip fL fL' — -
�srut,y��N� �941t)0-0-113 21.RVUARI;S Mu '
County 4 Parcel Identification No_(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lnti tom,is sufficient) 22 C rlifieatio
T9. 41 sx'-
6.Is(are)the well(s): %Permanent or lT empor?n '= Signature of .enified Xk Commuo - Date
Brsigning ttisftmi.1 hereln-certr•Ihat the urll(s)ieas(were)constructed in accordance uidz
Is this a repair to an existing well: ❑Yes or *_o /izl A'C.1C 02C_010D or Ji.4 MCdC 02C.0200 11'eft Conshrurtion Srardards and that a copy-
Ir1h&it a repair•fill out knonn well constriction hiformatian and erplaitt fire,atare ortbe gf1his record has been provided to the urll onmer,
repair tader a21 rennarkr section or on 1he hack of this farm
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Weils hating the same You may use the back of this page to provide additional well construction info
construction,only 1 GR'-1 is needed. Indicate TOTAL NUMBER ofwells (aaa'See Over in Remarks Box; ou may also attach additional pages ifnecessary.
darted•__ /
_ 24_SUBMITTAL INTSTRUCT(ONS
9.Total well depth below land surface: ��S (ft.)
Far tatd6ple nulls list all depths ifdijferear(eraurple-3�?�0'at{(t Nth100) Submit this GW=I within 30 days of well campletiqu per the following:
10_Static dater level below top of casing: 0 - (fL) 24a• For All '"tells: Original form to Division of Water Resources (DVVR),
Irrrerter lerrl is ahore casiaa use••+ InfomntiAn Processing Unit.1617 MSC,Raleigh_NKC 27699-161
I L Borehole diameter_ (in.)t0 24b. For Injection Wc)IS:. PY
Co to D\VR,Underground injection Control(IUC)
_.
_ - Program-l6�6\-1SC,lta)eigh,NC 27699-1636
I2.Well construction method: A 1 2 Ro 7—'c1- (Z1 _
(i_e_auger-rotary,cable:direct push,etc) 24c For Water Supply.and Open-Loop Geothermal Return Wells:Copy to.the
county.envltonmental health department of the county where installed
FOR VV.ITHR SUPPI:Y W LLS Or\rL i': 24d.For Water IV i prod ucin1!over 100 000 GP!):Copy to DVIrR,CCPCUA
13a.Yield m
Ferrari Prograrn 161 I MSC..Raleteh,ATG 27699-i61 l
(dP ) Method of test i'q - ..,
13b.Disinfection type: r-W 0 r-t+e- Amount- �.0 0 Z.
Corot G%V-1 North Carolina Department ol'Eavuonmental Quality-Division of AVater Resources Revised 6-6-201 s