GW1--04726_Well Construction - GW1_20230724

WELL CONSTRUCTION RECORD fGW-1) ForTternal Use Only: `
1.Well Contractor lnforinntlon:
�^ (-AI
14.WATER ZONES 3
am �'�"t 1'h cC'lt1 FROM TO DESCRIPTION
Wall Contractor Name O Et. 3zo R. 'N011o1.1-)
liOC( 3 -P 3z o n• ysa (-1e It 0\_._.) .........--
NC Well CcalrrrJor Certification Number
{� i5_OUTER CASING ftbrmttld.msad wry bRLII9L►!t fir )
PLC) \J �V1lu _ 1 b,\S' , FROM
ft. TO ft. DIAMEIEitIn. 1iIC NPSS MATERIAL
Company Nye 16.INN/EllbASING OR TOEING fgenibamal dosed•lonp)
Z.Well Construction Permit#: Lk)a I — 05 a 1 FROM TO DIAMETER T CKNIVs MATERIAL
Usl all applicable welt ronsfniction permits'(i.e.WC.County.Slate.Variance.eic.) 0 R, j tp 3 O• CI-Zs--- uL 5)7 2 Z t PVC_
3.Well Use(eneelc well use): In-
i
Water Snpp(y Well: 1T.SCHEEN
PROM TO DIAMETER , SLOTSIZE THICKRESS MATERIAL
Agdculttual DMa i po!/Public R. n. In.
Geothermal(Heating/Cooling Supply) esideotial Water Supply(single) g_ r' in.
Industrial/Commercial °Residential Water Supply(mod) IB.GRour
ign@Oa FROM TO MATERIAL F3IFLACE:1MT MEMO&.L1rouNr
Non•Water Supply Well: O EL o20 tt. ItfiCtht rc FCx,t
Monitoring fRecavery IL R.
Injection Well: `
ft ft.
Aquifer Recharge EiGcoundwater Rcmcdialiob --
nutter Storage and Recovery DSaliui y Banter elo)1 TO�����; �)
m _F1tws.t ;1srerrMETHOD
Aquifer Test DSturinwaterDtainage ft a.
Experimental Technology °Subsidence Control ft. ' ft.
Geothermal(Closed Loop) DTr ecr 20 DRILLING LOG(attitdt additional shwas ff )
Geothermal(I1cating/CoolingReturn) fOtber(ratplain under#21Remadcs) -vltQti! TO nFst'¢tPrlolufmlor.�dmcssatuenart e.ensni�ezt _
C.) ii !(P 3 rt.� ( to tort-burl
4.IDnte Well(s)Completed:7-/0"2-3 Wen ID#„ 16'3 n• 5C5!t. 6 ti-Q NI
Su.Well Location[ Q' tit. 4'' r_ 1 li®6 p
M; c..1„o►e t R ;cite.e-
ft. R JUL �.
l'eelellitylOwuerName }-�� `1 FaneilylDeCiitapptIcaabllo) , 1J n _ h 1 LUC3
�•t t IL) C oi-c�-400. ra u5 !ar k(;!_';-I)8 1aCk It R lnfor�"a:i.n Prr�•C .Plg U►k
Physical Address.Ciry,eadZnp NICx1.Y\ t tit aS'(1 U rt. R. �a �
(A('ALVA' 1` Olu 3 d'O&5q 055 zl.REMARKS
County Parcel Idcntillcalion No.(PIN)
5b.Latitudeand longitude in degreesfminuteslseconds or decimal degrees:
dr well field,one latllong L ceffirlem) 22,Certllicntion:
35 G 351 o2 p ,q i)I.z301'N ga�L IS.I gq• 4 LI Ls -I Li ')W
6.Is(are)the wells) •'• „:'•i t or °Tempozmy tnfe of Certified Well Contractor Date
� By signing this farm,I hereby certify that the nvll(s)taus(were)connmrred in necordmree
T.Is this a repair to an existing well: ClYis or E]?"t with ISA NCAC 02C.0100 or 15ANC/C 02C.0200 Well Cengrstclien Standards and gam a
If ads Is a repdinlill ant 1..7+01m Wei c.mxuuati m infonirnlan and explain the nature of the copy of thirrrcord h"brea rrmvded to the[well aunner.
repair under021 marks section oron the hack ofthisform. 23.Sit4 diagram or uddidual well details:
a_Poe Cenprot,aDPT ar CIasad.Loap Coctfaar nal WEIIe having the Elmo You may use the hook of thin papa Io Dravida ndditianat well site domata or weal
tunsuection,only 1 COW-1 Is needed. Indiana,TOTAL ritimett or wells construction detntic_Tee any also tuancta additional rove iFgnaasan,y.
drilled: SURMTPTAL INSTRUCTION%
9.Total well depth below and surfeces50 S' (l3,) 24a.Foy All Wells: Submit llils farm within 30 days of completion of well
Far midge wells Ea all depths r(dffaent(example-3@200'and2 ,1ON) errnsauction to the following:
10.Shirk water level below top of casing: )41.0 (ft.) Division of Water Resources,
limner(evens abase casing,use°+° Information Processing Unit,
1617 Mail Stake ce Center,Raleigh,NC 27699.1617
1LBOtebole tllatIIeterl L1 • (In 24b.Par Injection Wells: In addition to sending the farm to the address in 24a
t'-l/ above,also submit one copy of this form within 30 days of completion of well
It Well construction method: (�
or.auger.rainry,ctbtc.direct push,cm.) J - COIISlITICtl011IQIh4LDllOWIDE
Dlviffitmof Water Resources,Cadergrmmd Injection Contra]Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Swim Cent%Rate6Eh,NC 27699-1636
13a.Yield(gpm) `7 mew of teshgeu. C64(zttilt 24e.For Warr Supply a nflcDn Wets: In addition to sanding the farm to
IOn the address(es) above. also submit one copy of this form within 30 days of
13b.Disinfection type:
Amounts �h 5 compll tika of mall eansiturtion to the calmly health department of the county