GW1--04362_Well Construction - GW1_20230707

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WELL CONSTRUCTION RECORD!GW-1,) For Internal use Only:
1.Well Contractor Information: '
s a ,e/ / � yGX� h et If'/1 ' 4CAIERIONF.S:a'diestitde iikl at:rgrigYMIP,P.,n`i4!$w:r "t:gLI,:1•` I !:
PROM TO OESCRIPTXON
Well Contractor Name I /)„
NC Well Connector Certification Number
a.1LVo1ZFEKO9tNCyN(ToF')iriiuTlF.'te$`pEifvelle),Oh. t{i'[u_il ItWEl6P:ea`p":a037;04
„{' eG�/1 13 r&s r '3/
p FROM TO DIAMETER THICKNESS MATERIAL
Comneny Name ��/ t —' 41 g It' i/ig f% ft. fo As- hu. SDI(2 ( rr.:,,P ..,, ,.
+1�OXSTfi 310/ttDIMi o`'ilielimilMrdid'd-136041;r: RIV4,:4'77,1. ..oli .
2.Well Construction PermitFROM TO DIAMETER TIcI3iaes MATERIAL
`• Lim all applicable well construction permits(I.e.UIC,County,Stoic,Variance,eta) ' ft. in.
• $.Well Use(check well use): Ir. n. le.
Water Supply Well: 1TK� *1•Itlaci ilYxi,t3f!v e.,1.0il;;7 :igN i :taiE:Vaa•.`r g
FROM TO DIAMETER m.Ot9IZE TRiCIWESsr MATERIAL
StAgrieultWal 0Municipal/Publie 0 ft, tr. in.
Si Geothermal(Heating/Cooling Supply) Illitidential Water.Supply(single) ft. ft, in.
*'industrial/Commercial DResidentiai Water Supply(shared) ;,y� y,..,p„;;. v,Ya,',`L't z.,�.9:•"{' °'';tt't`;... 'tiSk14 x!' " "y,,,e
,t��l].V��Y iS;,•y 6.IF..tif ,.1/. 7:•f1.17,;••J..:P:.N. .1 .�u N.t.:i4'A.v•.'.::'r:•tt.
e-- Irriion FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT•
ton-Water Supply Well: & ft. ;z g ft. tee jy y: �1 a,, '
,t Monitoring U Recovery It, ft. .11 a mil„r„
Injection'Well: `���
ft, ft.
11(Aquifer Recharge U Groundwater Remedietion
>fle.IS►1DICedVMPACK(icalPCatileii;isir4,.k4:400p ;".1*,-1;%:,0::1.1:% F.
Al Aquifer Storage and Recovery Salinity barrier FROM TO _ _ MATERIAL 'EMP1ACEMENT METHOD
111,Aquifer Test )Stonnwater Drainage ft. H.
II Experimental Technology ©Subsidence Control ft. ft.
All Geothermal(Closed loop) QTraeer , `rililliS 2ikaY3 fete mltu Til;eliiklbo'foeesaitila::.4 e.•:•Z;,?I::�4,:%.•0
TO
U Geothermal(Heating/Cooling Return) rn Other(explain under#21 Remarks)_ b O"' DESCRIPTION fwlon nudnmr,rolVraekrype.vain cite,no)
r G k �l ft' Areci7r, Sa . I
4.Date Well(s)Completed:,) `3/ z 3 Well ml z i f y •kt f' g 6,
Se.Well Location: r V A Mr' el 7,S�m Ate G-A
y ft. IL -�
Fnonity/ r Name r / �y �/° Facility IMP(ifapplieablo) R n• 1 =""r• e p ,.,i V I.- Vim`
-5 e A l CF/e$T` Ik ft. . I n ri 2071
Physical Address.City,and p f(; ft.IJ IJ_ 0 u
/�a/e'n 621 ICS C3ii.,:•;;i"m'::<I .P.:).::f,: i.',:iii0:r; ,':County ' Parcel IdontifiadionNo.(PIN) ➢n:�,:'Y v�_• ..... `-•'r
6h.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one let/long is sufficient) 22.Certification:
3 �' iI r f 5l14'9' N / 1551lk,°00.s- w s ;,3 / 2 3
6.lls(are)the well(s) crmancnt or Temporary
Si aofCettiS WellContrector Date
By signing this form,1 hereby cert71.that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or Bt `o with 15ANCtC 02C.0100 or 15A NCAC 02C,0200 Well Construction Standards and that a
;this is a repair;fill out known well oorcstruclioh infk-marlon and explain the nature of the coPy of this record has been provided to the well owner.
repair under P21 remarks section or on the back(Phis form. 23.Site diagram or additional well details:
6.For GeoprobefDPT or Closed-Loop Geothermal Welly having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTALN(]MSE1t ofwells construction details, You may also attach additional pages ifnecesseiy,
drilled" SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: • 2 f` (ft.) 24a. For All Wells: Submit this form Within 30 days of completion of well
Far multiple wetly dirt all depths ifdifferent(example,3Q200'curd4100� construction to the following:
HO.Static water level below top of casing:' ) (tL) Division of Water Resources,Information Processing Unit,
If water level is above casing;ate"+" 1617 Mail Service Center,Raleigh,NC 27699.1617
11,llorehole diameter: d Yg • (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Il2.Well construction method FrJ11 C`� above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(1,e,num.rotary,cable,direct peaketa.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: p�`/ • 1636 Mau Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) t Method of test i•s • rT 24c.For Water Sunaly Relate_etion Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:chime-/l ti Amount: l ® C X,, completion of well construction to the county health department of the county
'where constructed.
ornaGw=1 '. North Carolina Department of Enviroamental Quality-Division ofWaterResoaroee Revises2.22.2016
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