GW1--07408_Well Construction - GW1_20231117

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CONSTRUCTION:RECORD.:(GW�11 For tatemal use Only '
. -1:W ell QontrectorInformation:
. David Beicher .. 1�.wATeRzoNEs �..,. . . :
vl►oU C 4nt<nctor t amo FROM" To: DESCRIPTION
. • • 4594-A •,,?®& Ds1 e'- .5M'M (rcrvr%iirp`1 . . .
. . _ . CWellConttmtortertitisnttoaNember ' •• - - • - • •n`�• '-• ►5L�P1K_C r ckurt�
au • .
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k Drill,Ina. •• :FROM (forUTER CASENG .DIAMETER' THICKNESS ultionued wed OR LINER on- MATERIAL
' • :2.W Conateaetlonperndt#t't Teal 45. : -. . ' '• • MATERIAL. .
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Wag' FROM' TO ' DIAt'lBTRR _ .THICKNESS
pitiablewellconshucikmpermWile.UiC,Conu%SIatR VarlancAdc�) t}. • 1t. . •• 3.*non Die(check weliuse): .: : •: al• . :.-. : •• t' •: ,;In,. • • .
water SuPp4 won. . . . 17 scn>�r ..
tural FROM - To DiAtNL7Mt' ELOTSIZE THICKNESS MATERIAL
.. . .. peUPublio • • tti !t. m. .. .
3 pea -
1 : . piatrng/Cooling supply) • Ddeahel Wate . . -
Commeratal • ••DRResldeadal Water Supply( ). : .latato ::. . _ _- -
' Non water S°1!*..well:. : OM•••m 2 tt: . , EMENrML+7H0
Monitodnpi. .. - • ' . ..1311eeovery • t. It Chips •
•• .
• ra►IPr.Ac AMOUNT
Igleetlou Weua
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AgniserReoherge
. .�Llmnndwatet.Re►nediation
. . - ' very '• ' �gallaityBarrier .: .• • ns-._ . •TO ..PACK MATTERIIAAB) , . E LAc r Hon
Aqui Test : . •.. �1$tom¢wetm•DRiaage• .: -. '� p R '.. • • ..
Experimental-Teohaology .•: " ' •
.. �S1lbaldCIICe Contras, • .• :. • .!: .
Oeotkermal(Closed Loop) '•.. .: OTreeer• • '' .: - 20:-DRILLING Lots tat
tachaddalonafaheabtfaueweary) • • : •.•.• .
Gant>ietmel(Heutigs/CoolingRetum) •lOdter(explsiniinder#21Remaiks)- ':FROM .TO� � DFBCRIPr10N(color.trcda�r�on►ro0c�vaGxe.i..tae.et�) .
4:Date Weill(e)Completed•: it•10•.4 WSDID#.- : . . • :- ..�o ft'.. . d. tt.. 1)f' • 661 .
• ' Sa.W Locatbn: • • 40. B' 44,5.n
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: • Faouhyi . Nwaoe •
: f - • -• - _ : 3 O"'. : 2105'tt.• .l� dIYiii:<U-P • •
(� �. . .{ Facility ID#(ifeppltceb�)
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1'hYa a,City,eodZip '
00ge+ili : .:. .. :' ]96./.50firi ti Li /16 .21.RBD7ARR6 : - - V ;.- I .2023 . •
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5b.Lithindo end ioagitiido to degneed/minutei/aeMadn or decimal degrees: 'R ':;f `_ r 3
(IfwsU dromWritingIsmaidegt) E> .. . ���
• 22.Cettilicatlon: •
. .6:Is(are)the weU(s)GPermaaent ortlTemporaey• . • . . • • Signature of certl0ed Weft Contrlcter .. ' • Data
• • By.signing this farm 1 hereby aged/&than the w all(s)ivas.(ivan�)'conshucted in•eccordance • : •
7.Is this a ireP�'to an eid ting well byes Or o . . with 1SANCAC 02C:0100 or ISANCAC 02C:0200 Well Coiit ucilori Stmrdards and drat a •flthls b repalr.N.ioutiatoivri wellcariestatlon lon•mrd explaht the nalwv ofthe .Lappofthisme.F dhasbeanprmddedl0 the wall owner. '
1 Or .er.021irmar&aseetionorcn the baelcgfthisfonn. • j
• ' 23.Site diegeam or.addltlonalwe1detalla:
8.For ' be/DPT or Qoaed-Loop Geothermal Wens having tie s•ane use this:page toprovide additional well site details or well
Youthe bade of
• . - • 'c only!.0W-I Ie needed. Indicate TOTAL NUMBER ofwells concha on details. You may also a ch additional pages ifnecessary
dtlited: ' • '
{
S11B11O7'7'Al.iihi'It1TCTIONS
9:.Tomiweltdepw below land surface:• . • ..96,5--.• ( •) • • • l •Fordnul0 ewelt+daraprlapths(fd�eai(rr6mpie.3(rDpO'acd2®lOp7 Ida.1 WAN: Submit•this form within •30 days•of completion •of well .
consttactio. tithe£allowing: •: . i
le.'Sta�iC watarlevel,belowtopofcuing: • • .HA • . (ft. I ..
fi atarlevel'iaba'ved5O . - ) DivlelonofWeterResoluces,Ini?ormationPeoeeccbglinif,
r`ro d 1617 NIA ServIeo Center,Raleigh,NC 27699=1617 •
• 11:Ho I Ole diameter: fa.. . (1n) . .
b. r Inieolton Weflm. hi additions to sending the form to tile.address in:?Aa. . •
24 )fto
12.W wnafructlon niethodi - . 'R�r4 ,1 '(` • show,••als•o•submit•one copy o•f this form within 30 days of completion of well. •
,,, .ro>�. • constmotionto.the fbllowin• (Le. sable, - .
Division of Water Resources,I f de � .
. FOR WATER SUPPLY WELLS.ONLY• mound l<n)ection Control Program,
l 6 Mail—Service antler,Rab3g6,NC 27699.1636
' ' 13a.Y Md(CPS) 0_ e -
(} BZethod of teak �a�h$'1':!►tE �24c.for Wester.8unaly&Infection wens: le addition to sending the tbim to
c • the address(ea)above; also turbmit)one copy of,this form within 30 days of
13b.DWnfectionWe: NTM'O.%O Amountf '• I tin iy>e: completion of well construction•to the:counttet heaith,depaimient of the county
- - . - where constricted.
Foy .
I-1 North Carolina Dcpartmant of Environmental Qitality-Division of Water Resources Revised 2..22 2016
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