GW1--04328_Well Construction - GW1_20230626

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LL CONSTRUCTION RECORD 1GW-I' For Fnternal Use Only:
1.Well Contractor Information:
;YV1 t SCE CT, v K Ol S CV-) 1+i.WATER ZONES
�VcllCantractarhnmc PROM TO I DESCRIPTION
y-o e -- 1 6 ft. ��ft- )i p �� ._.
it. ft.
NC Well Contractor Certification Number ) i OYITER 1G(aarmulff.casea wells)OOL Otna -
1 t w� J ele A(-aC_, i 1 h C , . PROM TO BL46( _TRICRNESR MAMMAL .
I ft. ft.
in.
Company Name 16.1LVPfERCASINGOR IMIN sfgnnther--Eciose:Neap}
2.Wail Construction Permit II: o2 b 3 r(5 0 0 1 ? FROM _TO 1 DIAMETER TRICRNES9 MATERIAL
List all applicable well conslnrction permits(i.e.[IIC.Caamy.Slate,Variance,etc.) 8 R. /Q D It. (n 1 .1�'n. SD tZ 1 pi/C..
3.Well Use(checit well use): . ft. in.
Water Supply Well: 1T•SCSEIIY
FROM TO DIAMETER' SLO?S1ZE, TBICKNESS MATERIAL
" -grtculturat cipai/Publio R. ft,. in.
IL Geothermal(HeatingiCooling Supply) esideutial Water Supply(single) ft. ft- in_
VI IndustrialiCommereiat Residential Water Supply(shared) • ig.mow
INTIEtl alien FROM TO MATERIAL EMPAACEUENTAIETHOD&AMourrr
Nofl•WaterSupply Well: 6 €t. ab R• l .t 2 r 6(t,iC--
Mb Monitoring Recovery it. ft. -
Injection Well: — �°
f.
IIIAquiferRecharge IrtGroundwaterRemediatlon
lit 1•quifcrStorage and Recovery 0Saiintcy Satricr SROM �VE}rP�[ t
1 MATERIAL EMPLACEMENT METHOD
ill Aquifer Test E3SturniwaterDrainage ft.
f,Ilsperimental Technology DSubsidcnce Control ft. ft.
exothermal(Closed Loop) Ofiraccr 24 DRI IGLOGfattaeb.addiHanalshoetnifne ary)
Geothermal(Heatin,/Cooling Return) Other(explain Remarks) FROM TO n�etnt>�f)iu( traldnets sonhacktsve•Rtalnsize eicl _
4.Date Weil(s)Completed: ` .,1-Z3 Well DM kb R' 463-1t'_ O r--OM d-Q
Fe.Well Location: i ft.
ft
Facility/Owner Name Gta,(J RefillyiDeCdapplicable) ft.
6-4 &iu,t-e.1 CeivC, Uri C'e�v'd lPiel 'Pc 2 7M� JL'1�i LU13
Physical Address,City,aodtip 1 ft. ft. r Mr:t.^:l s7r�, :�;}�tl u!'r'A
;l r�r.
6u.hCtoYM3A, si(0969aS_3-qa oeo-
zr.� ��t .
County Parcel IdentiflcationNo.(PIN)
3b.Latitude mid longitude in degreeslminuteslseconds or decimal degrees: t
(if well.field,one ladle Is sufficient) 2.Certification;
=35° 36►S"0,0R7S4371N S2° (l 151., 10 n 0-1 )1' w
5- 3 i- z,3
6.Is(are)the wells) Permanent or E3Temporary wpm o€(citified Well Contractor Date
By slgttuig this form,I hereby eenify that the trellis)was(were)consumed;n accordance
7 Is this a repair to an existing well: Cillres or Of o with ISANCAC 02C.0100 or lit NCAC 02C.0200 Well Construction Standards and theta
tldJsiro repair.fill ma Imam welt construction information anti explain the nuturrofthe copy ofdds record hasbeenprovidedtathewellowner.
repair under021 remarks section aron.the back ofthlsform. .Site diag
ram or additional well details:
S_IPOr G'eoprabelDP'p or Closed oop Geothermal Wells tlaviag the saws You may use the back of this page to provide additional well site dennis or well
consttuction,vrliyl OW-I. IndiGatFTpPALIiiSirLBERvrwells
co�etiondeLuils.You may alsoaunchadditionalragecifaeeesaary.
drilled: /
�f SURN3i'f TAT.INSSPRUCI'IYEN
4. Jam(
Total well depth below land surface: (ft•) 24a.For All Wells Submit this farm within.30 days of completion of well
For multiple wells lut adept's ifdifferent(eromple 3@200'and2@l011) -construction to the following:
10.Static water level below top of casing: to O (ft.) Division of Water Resources Information Processing Unit limier levetis above Isrsittg,use"-I-" ,
1617 Mail Service Center,Raleigh,NC 276994617 ,
IL Borehole diameter: (o •-2$ (in.) 24b.1Tiar.Itliection Walls: *addition to sending the form to the address in 24a
above,also submit nett copy of this form within 30 days of completion of well
12.Well wnsinlction method:._ R /'Z
(i.e-auger,rotaty,ceble,drtatpash,uc� CDIISiIiIC[]OII tow fallowing:
FOE WATER SUPPLY WELLS ONLY: Di�ono€WaterRei°r�,Undergrounij Injection Control Program,
1636Mall SErVI a Center,Raleigh,NC 276991636
13a.Yield(gpm) (p 0 Method of Lest:ca). Con t net.24c.For Water Saipuly&Inieetinn Wellm la addition to sending the form to
the address(es) above,also submit one Copy of ibis form within 30 days of
13h.Disinfection type: el,16'i l t? Mnou tt "1' fTl,b i , completion of well construction to the county health department of the county
where constructed.