GW1--07407_Well Construction - GW1_20231117

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Vtgu,CONSTRUCTION RECO (GW y) Foo Internal Use Only:
1.We!1 Contractor Information: I
—5-RAf f e-V I t Si eel\l1 'C.,11f 0 r\ Mxoba I owO Des ora -
Well ContractarNam
ae' •
-I as A �M .J�� �Q 11e/
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NC Well Contractor Certification Number `4 ft. 40 n `5s G"r M ¶tli e,
Well Drilling, 15.WEERCASING(formuld +sedivels)ORLINERfir (cable)
S eph®Ilion s Onth $ , inc. mom TO p� ' D�r�nEa/ran. gam ,, ' aze�rnuvert_
Company Name C.
�l e" , D & C/`3 m S1) Pv C
\b i © � •16.INNER CASING ORTOMOfr atba asalcio Eteap) . -
2.Well Construction Permit& FROM TO- - DIAMETER THICKNESS ,MATERIAL
List all applicable aat:ld ca=arctkra,p rets(ie.(IIG Carte:Sham 3rmim c etm) ,, �Q ire.
3.Weil Use(cheek well use): - , ft. IL ' in. •
Water Supply Well:
FROM 1 To —DIAMETER St4'irS3eE . 'rIIYCIO SS MATERIAL
icipul/rabile ir. An-Geothermal(Heat ng/Cootmg Supply) .JResidential Water Supply(single)
Industrial/Commercial IV/A
�IRcsideatio1Water Supply(shared) 18.t 4ffF
Irrigation STON TO xra r®r. ' E Cb>�Vl ti�Effi0J3 EESit30tTivr
Non-Water Supply Welk
Monitoring C aQ )erito "Po iA e, [-I 5a 1 b, ha3�.-
Monitnring �Rccavcry fi, Ch,1 p ;
Injection Well:
T
golfer Recharge Ohmura Remediatkm
Aquifer Storage and Recovery oSalittily BarrierM.--SMIIt1C-IAvs€,F�Ct1(It' BIe)
FROM TO it;ATERL6L 1zNne>tst€n.-a araton-
11 Aquifer Test DStotmviaterDrainage A R- 1 R .
i ..,edmentalTecbaology EiiSol deece Conunl ft. ' •
Qaeothennal(Closed Loop) DTracer 30 DR PTGLO G Werthetlrineovat ifr ,ivy) . .
7/Geothermal(HeatinglCooling Return). Ell Other(explain under#2I Remarks) cram TO DEsca••Fricej.is''ro>:tm �r,s3t a2nriadatyga• ran c3�)(i . /. ' .'TO ,CO!I _
4.�� ; ell(S� Q�pl d;l I-—1- a3 WeII aF 1 I ft. ; f.t• &c` 1",mil': r✓1�.
5a.bVell7Loeatian: 0 Q ft. —7"1. k''
C:an ttere- 110541e r` 15 ,Ik I�e.rro. Li 10., : C-,`s ft. `k65-fr, • _ae,14 • . :-.
FaciiitylOrrnerName -Facilkap#agiillerbte) -- tL th :. .
4.Q J3a.ri/ el-p FrtankhiCfsa � Ails- a:-C Sa 5; -
Physical Address.Cuy.and .. , . . :R. • -.• -r. ,._ L ?.,-.'.r , e.�'I 1 .
Frank!A� ,�- rt, r�
CountyPaacel ldentificatioallo.(PIN) N O V 1 L ?Q 2 q W
Rh.Latitude and longitude in degreagrabu„disliwiiminor decianal dam: .. .
(ifwali field,one tat/long is sufcient) .22:'t rti#issdion: E j r . .!eJe I
3S° (A' /3'/ ' N —1l° a�' 4�7J' W --,
6.1s(are)tbeYvell(S)i ar!naneut or �jTempnrara+ Sa_.5? a. -•WetlCor ' Date
" ',3.1gaieig 0/Tiff/Tx.//lady can rj&F rt the.icf1(J t )mitt ateardbrte
7.1s this a remit to an misting ng: DYes.. or Nc n711r15tlNCi4CO2C_010DarI:iAlJCtC t12C.cgoo Well Caasfiuctian S tatidards and that a
phis isarepau,Jillmahaawa wall ea:crtruetianiafirfuatioa tad captain the natureoftha cola'etlris eio?zdleshe2aprovidedtotfieaceliau:
' trpair under#21remarls seam area the back ofthsfara. .. .
M.Sita dlegrsta.or addidanai well detests::
R Iror C-eoprebelDP?or Closed-Loop Geothermal Wells having the same :'You may-use the back of this page to,provide additional well she detal or well
constructiop,only 1 GW-I is needed.Indicate TOTALBIUMBERofwelLs. . constiitcliondeiails_Youmayalioatlachadd'ationalpagesifnt aryl
drilled: 3. [ supwIj'AL misra clioNs
9.Total tell depth below Iaaatlsurface: 9 ( ) 24a.For.All:turtle-' Submit this farm within 30 days of completion of well
For multlplewells listalldepthsIfireerant jerample-3@200'and 2Q100) construction'to thef:
3t).Statie water level below top of casing: 3 5 (ft-) Division of WaterResnorer s,Information Processing Unit, -
If►ruterlevel is above casts&vse.-t-- 1617 Moil Service .'enter,Raleigh,NC 27699-1617
11.Borehole(fiamett r: (tit) 24b.)±or Thieeilin.- fells: In addition to sending the form to-the address in 24a
Al
r �0�a r above,also,.submit_one copy of this form within 30 days ofFcompletion of well
13.Well cons/ruction method: Aconsatictioa tp the following: 1
(i.e.auge,rotary,cable,directpusb,eta) •
t ?rvlscauaf t aasae i erection Coa>*rol?zogram,
�RW�.T'$tSIj#I'LYWL_s`.,sONLY: ' 611�163miService r,Ralargb,NC27699-1636:' 13a.Yield(gpnt) 6 Method of test G-a(JI 5 24c For Water Somali&c-Inteetion Wells: In addition to sendingthe-form to
J_ the addita(es)above.;aiso submit one.copy:of this:.than withia,30::days of
13b.IDisinfection type: /T I /��1 Amain~ J.- /D r completion of weir construction to the counti health:department:of the county