GW1--04269_Well Construction - GW1_20230626

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WELL CONSTRUCTION RECORD(GW 11 • For Tnterrnat Use Only:
1.Well Contractor Information:
i/n rh r(tyl V\i bsG' 1 14.WATER 7A)1NES
Well ContractorNamc FROMTO- DESCRIPTION
foc13, oft. q90 ft- , 1 bl iOl.J ft. I ft. .. 1
NC Well Cnntramor Certification Number
1.1 t?0tFTER CASIlNt:tihrmtlltt•cased weirs o 1NER tlta 1 omo _Z V i C..Q-•&-i I Yl L' - FFROMTO DIAMETER THICKNESS MnTERIAt. --_
Company Mane
fL fl. in.
16.INIILCAJSNGOR€ll13ING(geothermal closetl loop)~
2.Wall CoilkinetiOliPernlitk —0 5 9 FROM TO DIAMETER THICKNESSMATsarAL
List all applicable well constnictianpermits(i e.ElIC Cannty.ytate.Variatice,etc.) 0 ft. 3 O tt. 6 2 5- 1n. t5 DTL21 P vc-
3,Wen Use(check welt use): ft. ' in. 1
Water Supply Well: 17.3t:RElsN
Agricultural FROM TO DrantBrgR sLOTstZEI TglCt�ypSS ALlTggftL
�MuniciF¢UPttblic
it: ft. 3n,
Geothermal(Heating/Coaling Supply') i analWatersupply(single)
Industrial/Commercial
fIndustrial/Commercialtesinential Water Supply(shared) . B.GROEIT ---�----�
• 2ET{$IlttOa EMI TO MATERIAL IIMPLACE1,1ENTMEITIOD&AMOUNT
NoII Water Supply Well: ft �"cc) ft. t 11 Cat .
;Monitoring RrxoVcry te�r -
jilt
Welk - ftal
.
MI Aquifer Recharge DGmundwaterRemcdialion ft. I
yuifcrScorage and Recovery mtSatinity Sorrier 19 SANDIOSANE2.pACR firtmplirable)PROM To unrsetat
At•quifcr
StaralwatcrDxaiaage IL ft: �mtac murntErson
I Experimental Technology 0Subsidencc Control it. ft.
it Geothermal(Closed Loop) OTtacer 20.DRIL ING LOG(attach additionaishoetsenectssort.
"Gratherme'(Heating ',Other Return) ,Other(explain under#21 Remarks) a�1TO as` QNfm� �u/r�tit e. ias;u�l
6 r:. - c% CIS.IO
"C1'17GtE Ce�1
4.Data Well(s)Completed:s a 11 23 Well er .to it, jott, It.
Sa.Well Location: 3() it5 2 r tr.-
ay.4IN 111-e
C.tr t 7ctne Si,�i1fU ft. ft. _
GaellityldwuerName FacIlisy WOrrfapplieable) ft. ft. "',�, 'E,,..*f...-u y,' ti,...,...:
) HU,i b•er Cs Cc.l•e t irc.,c,ce, n%C 7? 7 Iz- JUN 9. ; 2023
-
PhysicalAddreas,CitytandTrp ft. ft.
•
l trconsyl vc. i'cr 9 c1:3— -1-5704- .. .:: :.:� �,�.�
County �:,;; ,_., :'
Forcer Identification No.(PIN)
3b.Latitude and longitude in degrees/rninutestseconds or decimal degrees:
Orwell field,one latilongIs sufficient) 22,Certification:
•
"�____- 5--2•L!-Z3
&Is(sra)the welts) ent or DTemparary igtmtute o€Certified Won Coattaster Date
7.Ys this a repair to an existing well: or t?
By signing tttir jbrm,I hereby eenify that the trellis)was(were)constructed in accordance
with ISA NCAC OW.0100 or 15ANCAC 02C.0200 Welt Construction Standards and that a
rftl is a,•..parr,flit out t'no nwellconstructiontnfarnwftenandexplainthenatureofthe colic'of this record has been rraoidaf to lies welt Owner.
repair under 621 remarkrseetionoronthe back ofrhisjorm.
23.Site dinaraa¢oraddrtinaal ouch doeaua.
:Liter CenpraheilPT or Closed- Loop Geothermal Wells having the same Yon may use the bock of this page TO provide ad.littonat west oho depots os wen
conatruetton,only I OW I is needed.Indicate TOTALAIEJMBER orwclls construction dettuiL. You may also attach additionalpngns ieaeeaaoaty.
drilled:
RURM TTAI.rasCTRUCTIONs
9.Total well depth below bind s:a m: 5-',2 r (ft) .
Formate(plewellslistatfdepths(lr)ijjeremt(emmpic 3�00'and@I002 '} 24a.For All wen• Submit form within 30 days of completion of veil
•
1" construction to the following:
10.Static water level below fop of casing: 2.t.p O (ft,) DivisionRe
of Water sources,Information Processing Unit,
If water level in dam casing,toe'÷" 1617 Mail Service Center,Ralelgb,NC 276991617
Ii.Borebolediameter; CP f Z i
Cam) 2db.)ier ifnieetion Welts: hi.addition to sending the farm to the address in 2da
12,Welt construction rnetliud: IItD{CZ yI./i above,also submit vac copy of this form within 30 days of completion of'well
(ie_aager,rotnry,cabigcdmrp ,VC-) '��� C4Il5iItICIIOQto#heft]11fltVlUg;
FOR WATER SUPPLY"WELLS ONLY: Dlvibionof Water Resources,Undergroand Injection Control Program,
16361 'ail Service Center,Ralelgh,NC 276991636
lea.Yield tgpm) tS Method DMA;TA.I1 eo ci fi r14. 24c.For Water Supply&Infection Welk' In addition to sending the form to
13h.Disinfection type: al(Oti'1 Amounts 5 -• z,it c the 9ddIess(es al
so 1S0 submit one Copy of this form within 30 dour of
a,.n.,a..r..... ..c...-n ls