GW1--04743_Well Construction - GW1_20230724

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WELL CONSTRUCTION RECORD(GW,11 : For Internal 1.10.0n1)r
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:FROM - TO . DESCRIPTION•
'WcliContractor Nartar
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, '....., tic WeliCoattoptkcertigcntion Number t -:15:OUTERVASING.(for multi-eased:Wells)OR:LINER-(If
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7 AMLI LH TRICK.NESS ii-leuAblTiE)
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COmpany Name
.,,..1,2 •,,•16:DINER CASING ORTUBING(geotherinal clo.sed400p),:'..:-'•"-.- ' -•,:;. -.'1•1,-..-•. •
2.Weil Construction Permit#:. it.,/, 5c2047... ,60&,,y7 FROM ' 'TO -'-•-•DIAMETER"' '- I-mamas' MATERIAL.
LW all applicable nedi.catutruetion 'ts ae.UIC,'Vounty;SiatiVaiiarice,etc.) ft., -ft. ' "io-•
3.Well Use(check well use) '•
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Water Supply.Well: , ' OM. . TO . DIAMETER SLOT S - THICKNESS MATERIAL.
°Agricultural ONIonieipal/Publie /Wift': A/ft': -2, '1°-: (:4'..04 . i4r56 fiPC).
°Geothermal(Heating/Cording Supply) )41.esidential Water Supply(single) ' ft: ' it. ie.: .
Olndustrial/Commercial °Residential Water Supply(shared) „It;GROUT
°Irrigation ClWells>.100006:GPD ; 'FROM - TO ' MATERIAL EMPLACEMENT.. 1013&AMOUNT
.)21-1/5:
°Monitoring , . ,. ORcetivery .. , . ft.• !i.:. ' - l' - - - -. —
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InjectIon•Well: ' ' - - • ' ' ' ' ". : : • ,
• :. ft.::: ft:
ClAquifer Recharge OGroundwater,Iternediation ' --- . .
19:8AND/GRAVEL'PACK(lf applicable)-::••"'--- •-•,2"',:,..r. ',:. - , : ••' ,.,:--.
•ClAquifer Storage and Recovery °Selinity Barrier -f ROM ' TO . •MATERIAL , EMPLACEMENTMETIIOD
°Aquifer Test CIStOnnwater Drainage• 4•V ft-.. /0 k---7(Willfreff • /6",,,,tiyAce.,fr„.•;i1---,
.. . , . . _
°Experimental Technology- ElSidisidence Control. R. ft., . .
°Geothermal(Closed lAion) °Tracer., -20:DRILLING LOGIattich'additiaital sheets If necessary),. , - . . -: •-:. -
FROM fi.,IDGeethenual(ileating/Cooling Return) TO " - DESCRIPTION(color,hardness,solUrack trim,grain dee,etc.)
rn) Ob, _ ther(explain under fill te Itnarks) ' FL-:
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4.Date Well(s)Completed: 4 :4.gWell,ID# - : --- - : .-3s- ft.. .. .?i,eft..::, 40p..., /, 4,freirierlistrvt
5a.Well Location: R.ft* ft; i/-4,..-I ir: -_,"•.,-'''4j-:-...--1.Al%6/AO 74A
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fL.' $,Z>7 e.,acii- cI:fft: 11:Pae.. Afc.01Tric.71e1
Facility/garner Name, Facility1D4(if applicable) ., _ fi:',: ft- r•-•, 7••• ''''‘R''.•a.. /t Kt........
i 6.6g g lisA 24',, 0. Lii4Yiyhk. . . _it
hysjiral Address,City, • / , . ft. ft.:
ff. - C=LiCiti VtL)
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....,„,,, Parcel IdentiEtiotion No.(FIN) . ins-7r.ali,-1 prn,a.a../jor:0 Jr.,..
. .Sb.Latitude and longitude in degreesrminutes/sedotuis or decimatdCgrecat CM/CF./BOG
(if well field,one IsUlong is sufficient)- e 2i Certification ' . - .i
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6.Is(are)the.well(i):yrrnanent ..or OTemporary S o rallied Well Contractor Da "
signing this form.1 hereby cert6 thatthewell(s)Was(were)constructed in accordance with
7.Is this a repair to an existing well: °Yes or ta(to ISA NCAC 02C.0100 Or ISA NCAC 02C,o4o Well Construction Stiuzdards and dua a copy
If this is a.repair,'Wont known well construction Wart-nation explain the noire of Me of this record has been Pmvided:°the well wner•
repair under ad1 rentarla section or en the backof thisfirth:
23.Site diagram or.additional Well details:•
8'.-For Geonrobe/DPTor Closed Loop Geothermal Wells having the You may use the back of this page to provide additional well construction info •
construction,only 1 OW-I is needed. Indicate TOTAL NUMIIER.olwella (add'See Ovie;Initettuulcs Box).You may also attach additional pages if necessary.
dulled.
4). . . ; ... 24.SUBMITTAL INSTRUCTIONS
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9,.Total welIdcpth below land surface: :f'•(f-r:..,/i0 04 :
For multiple weaslist al!depths if dillerrns(example-3C)200'and ©I try. Submit this,G*Ilvithin 30 days of well completionpe .the following:
10:Stade water level below top of casing : 10 ,..., 24a. For.AM:Wells: Original form to'Division of Water:.Resources (Dllifft),
• - '(ft) Iriforthation•PpacCiaing Unit,1617:NiSC,:Raleigh,NC 27699-1617
trwater,diectis dieve casing.ase 71-L i.... qi.
24b:Mir Inleitlon Went'Copy to DWR;Unilergrotmd Injection Control(11J‘C)
11.,BorehoIe diameter:. 7 7V (in.) ::::::',
p..,._,..::, PTOMni,16?0MK 140eigh,..IOP69P;10.30
12,WeReortstritetiOn Method: tirtEA el irOtai'V ' 24c.,For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.augti,MuirY,eable,dittet path.etc.) county environmental health clenarrment of the county where installed
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FOR WATER SUPPLY:WELLS ONLY: 241-For*Water Wells producing gier 100,66 0 dtb:,Copy to DWIl,' cerevA
13a.Yield(gpm Method Of teSt:
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Peraul.Frograrn,1611 MSC,Raleigh,NC 27699=161.1.
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'13b.Disinfection-type: . Amount: ..). cY9-,..,
Form GW-I .-•-•-•- - -- ' Nordi Carolina Department orEnvIromnentni Quality.Division ofWfatcrItesources: Revised 64-20I8