GW1--06408_Well Construction - GW1_20231009

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WELL CONSTRUCTION RECORD For Internal Use ONLY: j
This form can be used for single or multiple wells -
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1.Well Contractor Information:
s / ,
_ -_.J e Ffre y i d.CG/7 e'—� r/ce r, ,4'%c FROM TO _DESCRIPTION
fell Contractor Name ft. ft. ]tQd `1 4
0 1
4'i 6 c) 2 . ft. ft. I l
NC Well Contractor Certification Number ':15:OUTER CASING(for multi-cased wells)'OR LINER:(if ap licable)''': .:
•� FROM TO DIAMETER THICKNESS MATERIAL
22 C, IT)u//is5 We// Vr.;1- i/� Zi1/c ,.p,1 ft. 95 ft- 6 ! in. i 4,2 5 i° C
Company Name '16:INNER!CASINGOR:TUBING`(geothermal'closed-loop) .:
FROM - TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit 11: R ft. ft. in.
List all applicable well construction permits(i.e.County State.Variance,etc.) ft ft in.
,, 3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in,
OGeothermal(Heating/Cooling Supply) lTidential Water Supply(single) ft. ft. ;in:
❑Industrial/Commercial 0 Residential Water Supply(shared) lsi GROUT:';:.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation Non-Water Supply Well: Q ft 4;1 ft.0 Ten' 7i 04/4e fOcc r ec/
❑Monitoring ORecovery ft. ft.
Injection Well: ft. ft. i
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK(ifapplicable)•- •: ;°;-. :-_I :a;:•.:.` .'.'';:
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft ft. I
❑Aquifer Test ❑Storinwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control
20:DRILLING LOG(attach additional sheets ifnecessary) ,<> .
OGeothermal(Closed Loop) OTracer FROM TO i DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
OGeothermal(Heating/Cooling/Return) ❑Other(explain under#21 Remarks) 0 it A,80
O ft. I?Q Cl C.16t.y
4.Date Weil(s)Completed: / - 1 ,23pZ R [n�(� f t S � STD }
y 11 Location: ;' 3 O ft g 5ft �/_ e A.,61/h-
ft ft _
Facility/Owner Name Facility ID#(if applicable) ft ft. r" ( 1 •
3 3$ Dell'n h;re VR, ill+- CA, I a - ft ft. rTT r - .....
Physical Address,City,and tp ;
��� p h��j 21:REMARI{S :. : _.
•
D u/cLn fflllvi 11, In _
County Parcel Identification No,(PIN) i .'�
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
3.J. to& I3 I N ge)I 76,6 < 7 w / 17` l 723
/�� a o e ed Well Contractor Date
•6.Is(are)the well(s): k(Permanent or OTemporary By signing this form,I hereby certtfy that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
.:'''7.-Is this a repair to an existing well: ❑Yes or IBIVo copy of this record has been provided to the well owner.
!fthis is a repair,fill out known well construction information and erplaiu the nature of the 1 -
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
/ You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: ! construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can I'
submit one form. /�/ C T 24.Submittal Instructions:
9.Total well depth below land surface: . . f/ .. C� (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2(g100') construction to the following: ,
' 10.Static water level below top of casing: 3-7 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617_Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (0 //A (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
/� above, also submit a copy of this form within 30 days of completion of well
�—`tiit.Well construction method: /l Of'a r 11 " - construction to the following:
e.auger,rotary,cable,direct push,etc.) J i
w, Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(rpm) Method of test: p s'r 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
the address(es) above, also subunit'one copy of this form within 30 days of
�.�( 3 completion of well construction to,the county health department of the county
13b.Disinfection type: 4 r Amount: e_h 175'
where constructed.