GW1--07221_Well Construction - GW1_20231108

WELL CONSTRUCTION RECORD For internal Use Dray: i •
a this tern)MIRbe ms d for single ormultip le wells j
1.Well Contractor Informntlon:
77�� EL MUTER zQN)rs . I I .
7). G• `\4(�57. FROM TO 'Mammon •
Weft CommettorName 7G ff. c:PO R' Co 1 k-E U 614-1-G 1cS1 SR•ti(p
Arc ltl C D_5Sa-A- ft. j
NC Well Contmctor Certification Number l5:OUTI CASFNO(tbriniaptiOtisen*ORLINEROfo blo)
FROM TO` WAM[dTTIffiR TAiC(WES$ 1HATE IAL
t 4-ivyE R (c r t 1 _&k (..c,1( vuhke o ra ft. 0._. -'-. im Sc,t ilv E_
' 16.INNER CASING•t1RTYiB12Y(s(geothermal eta local
Company Name FROM ' TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit 6: Pt. ft. la
List al applicable!1pismits 0.e.County, e,VOttmwe,lnJealkn,eta) - y ;u ..
3.Well Use(cheek well use)! l4. N •
• FROM TO DIAMETER Rt.OTSIZE TaitKNEES ' ssocrIAL
t ElA�griecultur wsu: OMunicipal/Public ( 70 it. ct0 l a t c. l Sch. t PfrK,
CaOcuthetmat(Heating/Coaling Supply) OResidartiui Water Supply(single)
Qlndustdalrommeueia! DResidential Water Supply(ehered) 1s'. •GROvr. . ...! ; u i
FROM TO MA. TERIAL EMPLACEMnsao2sttODaemovNT
dAligatim B VVdI: 0 f' POvi`. ,41
Non-Water Supply ft. ft. .
- 12Monitoring` - OReetsveey --- — - -_ - - -
tgiecllon Well;
OAquiferRecharge °GroundwaterRemediation ••19.SAIt1lGBAIVELPA itrapplieabkt •
ClAminfer 5t and Rerav ❑Salinity Barrier
FROM ' TO MATERIAL ' EMPLACEMENT METHOD
OAgtriii r Test gStotmwater Drainage • oZU °' 5a tt. /.ft. ft. I6' ikt. Po v k E 6
r7RxperimerrtaiTeohnology 03ubsidenceControl •2OR1LLINGLpGIattachaddtttennletteeiiif mcoissrsl
E3Cmothcnnal(Closed Loop) Moor FROM TO DESCRIPTCON(color,Oxidant,mithack type,pato din,etc.)
Cideothermal(Heatirg/CoolingReturn) , LlOther(e,cplainunderd)21 Remarks), a ft, as F' ,A•%.(a
uky
4.Date Well(s)Completed:r6/d-3f o23 Well IDN a` S 5 G ��4 C
Ss.Well Location: s5 5 fir 80 f Ccr.c st.LLGH.'f C�a,k.-r ' V't b .
r D '90 sist4 .jcL1w) .hate,
4.4/ to 4 GLeA-by Wc/LTA'u4 ft.` f. • -,-- •? . :. , --
FscllitylOwncrNeme Facility SW(if applicable) !L - • y:..,T. li.1n,it.
/ is 1/4/E(4-r i4, J E&-rFait.A1.C. a. L�F ft NI IV v S 707
Physical Andreas,City,and zip • 21.REMARKS .
County Parcel Identification No.(PIN) u•;:k.,:�` 'i
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
((fuel(Reid,one(alliong is stoicism) ' '
3(e.1S7 ( �. N— `7Ce,3'7GCaCo w ia})_ mils m/�3la
Signature*Mortified Well Contractor 1, Date
6.11(are)the well(s)t` er anent or DTemporary ay signing this rrm,I hereby(Newt&that the,ren(�,rm(were)eoxrtr ueted in mxondaaee
_ _ _ __ with 1SANCAC 02C.0100 or 154 NCtiC 02C.0200 Inn ConstnicOon Standards and thata
7.h lids a repair to an Ms-dog well: Dyes or p . copy ends recwid tetra been provided to the 0111 owir ri -
Jjihla is mpalr,fillonIlotmwr well ce nstmction learetatlon d explain die nature of the 23.Site diagram or additional Well details:
You A71.rerarkr auction ar on the back of thirform You may use the back of this page to provide additional well site details or well
• S.Number of wells constructed: • oonetruction details. You may also attach additional pages if necessary.
For multiple injection on non.water supply wells ORLY with the same cons rm:O it you con
submit o ne.lorm. SUBMITTAL INSTUGTIONS ' i •
O.Toad well depth below land surface:. 90 1 (lit.) 24n.For Al(Wells: Submit this farm within 30 days of completion of well
For maple wells list all depths 9 digireat(emample-3g100'mrd2®100) construction t0 the foi owing i "
10.Static water hvel below top°teasing: /! " (ft) Division of Water Resources,Inibrnaation Processing Unit,
f raur t'e,ael fa above cams,,use 0,... 1617 Mail Service Center.Raleigh,NC 21699.1617
H.Borehole diameter: 6 (im) . 24b.For Inieeton Nona ONLY: In addition to sending the form to the address
24aabavq,also submit a copy of this form within 30 days of completion of t
12.Well construction method: MA/ e i 4 L1r construction to the following:/
(ie.auger,rotary,cable,direct push,etc.) c
Division of Water Resources,Underground Igjeetion Control Program,
FOR WATER SUPPLY WELLS ONLY: • 1636 Mail Service Center,Raleigh,NC 27699-1636
�ry '• 24c.For Water SWpuir tit Infection Wells:
I3w P Yield(gpnl) Method of tgts PU wits
Also submit one copy of this four within 20 days of completion of
Cal-a poei-ith_i Tr well construction to the countyHealth d 16mof the c° whore
13b.Ditdaiee ontype: Amount `t 0-2_O . constructed.
Form GW-1 North Carolina Departmental Environment and Natural Resources—Division of Wator'Relwcncs r Revised August 201:
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