GW1--03968_Well Construction - GW1_20230612

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.well Contractor Information-
i� tit hk r, I�. Yl 5 1� 14_WATER ZONES
Well Contract r Name "-'- --' FRO\I 1 D ------DESCRIPTION
ETC\l'e[(ConiraclorCertificatio nNumber `�0
r IS_OUTER CASING(ror multi-cased wells)OR LL\ER(irap licable)
Gl 51l`e-LI'5 W a« `JY�i��i b q `{1� . FRO at To Dl.w R Ttltct:sess MATERIAL
Company Name V L 4 fL Jc n_ \ in_ (3 1 D c-
MINNERCASINGOR TUBING(grnthermal eloscd-ioo )---`----
2.Well Construction.Permit 4:-_ ��� �7 jp �. FROai TO I)MMETER TD1C1= \I.ITERL\L
List all applicable ui 11 catutructioa pmrrirs%t.r L'IC.Comm;Srate.Maritime.etc) It. It. in.
3_Well Use(check well use): IL ft. in.
Water Supply Welk 17.SCREEN /
FROM TO DL•t\lh-rL•'R SLOTSIZE TIt1CKNESS MATERL\l.----
❑Agricultuml ❑Municipal/Public n_ It. in.
❑Geothermal(FleatinJCooling Supply) W sidcntial Water Supply(single) n_ rL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18_GROUT
❑Im;ation ❑Wells>100.000GPD FROM To 3LATERL•\L E\IPL\CE\iE\T�ILTitOD&.�\toti r
Non-Water Suppkv V Ie)I: 0 ft_
❑blonitoring ❑Recover} iL fr.
injection Well: r ��
iL ft.
Orlquifer Recharge ❑Groundwater Rcmediation
I9_SAND/GRA1�L PACK(iCa plic vblc) — ------
❑AgUlfer S10ra;C and RCCOVCry ❑Salinity Barrier I•RO\I TO \L\TERL\L E\IPL•\C.6\i):\"i\IE7IIOD
❑Aquifer Test ❑Stormwater Drainage it- - «-
UEaperimental Technolon• ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 21L DRILLING LOG attach additional sheets if neeestan•)
❑Geothermal Hearin/Cooling Return UOther FR031 TO DESCRIPTION(color_hanlaess soiUrack h c. :n sae.edG1
( ) (explain under=21 Remarks)
e Lt ( C�Q
4.Date Wells)Completed:E(b O well ID-- -� l 9 5 .. n_ ft. 11
Sa..Well.Location:. _ f[. c28
' wl "
ft
Pacilir)iOtvnzrNamc FacilityiDi% f. S;..r o 1 0
� 26233
f hysical Address`,Cih•;and ip ft` It- lJ J I :r
(f1f_1iL1'\\J6l,�s 21.MIA ARKS -- n .......,.,.:a
Lin",
l vsr+an.a.
County Parcel Identification No.(PIN) p\ljQjti(a
Sb.Latitude and longitude in degrees/minutLs/seconds or decimal degrees:
(if nzll field,one.lnt/tong is sutTckno 22 rtificatjon:
t. y '�5 o S1 W �-
� ` ' Si u urc of golf d 'e11 Contractor
fi.is(are)the\vell(s): crntanent or l7etnporan' I)a!e
Uesignbta•!h)sJutnt.I herehd•rerun•that the ii ell(s)iras(were)coustrucled in accordance uidt
7.Is this a repair to an existing well: ❑Yes or 0 15d A'CAC 02C_011)U or IS;t t\'CdC 02C_0200 Il ell Construction Standards and drat a copy.
If dz&is a repair.Jill out knouat yell construction btfonrtation and explain the nature ofthe of this record has heen provided to the well owner.
repair under 121 remarks section or on ire hack aJ'dris faun
23_Site diagram or additional well details,
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells hating f)ic same You may use the back or this page to provide additional well construction info
construction,only 1 GkX1-i is needed_ Indicate TOTAL NUMBER of wells (add'See Over'in Remarks BoxJ 1 ou.may also attach additional pages if necessary_
drilled:. j
.tom_ 24_SUBMITTAL INSTRUCTIONS
9_Total well depth below land surface: L J 111 n (ft.)
For muhiple yells list all depths ifdi/erenr(erample-3rr_a7200'and 2lri!10U� Submit this GNY-1 within 30 days of\yell completion der the following:
10_Static water level below top of rising:..-_. 24:L For-All Wells: Original form to Division of XXIater Resources (DIVR),
.. 3 O (ft) -
ft i aterlerel is abovecadntr use. InfOmriyog Processing Unit 1617 MSC,Raleigh.NC 37b99-161;r
11.Borehole diameter: (in_) 24b.For Iniection Wells:Copy to D\VR,Underground.Injection Control(IUC)
'ro=ram_ 16�6- SC,Raleigh;NC 27699-1636 '
12.Well construction method:. -
�� -4c.For WaterSupply and Open-Loop Geothermal Return�i'ells Co to the
(i_a.au�cr,rotary.cable.direr[push,etc-) PJ',
county environmental health department of die county where;installed
EOK-NI r#TER.SUPPLli WELLS ONLY: 24d,For Water'VVells producing over 1 10 000 GPD•Copy to DXIrR.CCPCLra
13a.Yield g m Permit Program,1611 M.C.Ralctgh,IVC 27699-1611
(bP ) 1 CAD
( Method of test: y
13b.Disinfection Npe:l CA b f mount: 1 7J Fj7 ,
Forttr CAVA North Carolina Department of Environmental Quality-Division of\Parer Resources Revised 6-6-20I N