GW1--07747_Well Construction - GW1_20231201

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well ContractorInformation:
Je3hiiSr" �t�4,11.SC.k-1 -14.WATER•ZONES• _ ' _ I --• ` - - , - •
Well Contractor NameFROM TO DESCRIPTION
y0 93_x} D ft• 7r ft• I Ho 1 l o'-.-
ft. ft. I' '
NC Well Contractor Certification Number 15:OUTER CASING(for multicaseduiells)ORLINER-(lfa• liable)-' • •-• '
I h D �e n v i C A , 1 /N C • FROM R , TO R DIAMETER In. THICKNESS MATERIAL
Companyl tNVam`e/ !L wi p , I 16.INNER CASIYG OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: I Q°8' l- FROM TO DIAMETER. THICKNESS MATERIAL
List all applicable well construction permits(l e.UIC,County,State,Variance,etc.) Q ft. 3 ft. ce.2s-In. ' 1 r S `
3.Well Use(check well use): ft. ft. in.
Water Supply Well: i7.SCREEN
Water
FROM. TO DIAMETER SLOT SIZE THICKNESS MATERIAL
il M .'cipal/Public It, ft. I in. -
Geothermal(Heating/Cooling Supply) NV' esidential Water Supply(single) ft. ft ! in-
*IIndustrial/Commercial DResidential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: _ __ - - . Q ft. 70 ft. Q.tan ik ftL
*Monitoring Recovery ft. R. al,
Injection Well: • -
ft. ft.
*Aquifer Recharge IDGroundwaterRemediation
. 19:SAND/GRA TACK(if applicable) - .... . - -
MI Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
It Aquifer Test OStormwater Drainage n• R• ,
a'Experimental Technology OSubsidence Control ft ft.
*Geothermal(Closed Loop) lO-Tracer 20:DRILLING.LOG(attach additional sheets if necessary) . .
-
i Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness,son/rock type grain s11e etc)
0 ft 38. ft. Nay/.0 2bc,t.r-ekt�
4.Date Well(s)Completed: 1 I- 7-23 well ID# 3 e. ft. .3r f-'ft (,/1'rotn,it "T `
5a.Well Location: it ft 4.. w
.1 o4.n 4- 3 1 afoc k. Ness ft. ft. n-r 4 s 9(123
Facility/Owner Name Facility ID#(if applicable) ft. ft:
is
1..8ct, Sc %ck Mi-, 1?d-, 8utrns.%AlIp I-NG - ft. ft. ,.....`-U. _ 0:3
sd
Physical Address,City,and Zip Q 9 arm?`r71
ft. ft.
y Q.t��1, l'• , 3OO �t�-,Is-zoo _21:REMARKR_. :.-. -- - - ..
County . Parcel IdentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 22.Certificatio
3S •g7S-14 d N S2. y coot% ° W _ '
6.Is(are)the wells) ermanent or Temporary u �bf Certifi I Well Contractor - Date`^ 7- L
� By signing this for e,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or �'V with ISANCAC 02 .0100 or ISANCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,,fill out known well construction information and explain the nature of the copy ofthis record as been provided to the well owner.
repair under#21 remarks section or on the back ofthis form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use th back of this page to provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction det s. You may also attach additional pages if necessary-
drilled: CITRM7'iTAT. c'r•RUC ICDTVs
9.Total well depth below land surface: 2 Li s-
ft
( ) 24a. For All W gills: Submit'this form within 30 days of completion of well
For multiple wells list all depths if different(example-?WOO'mid 2Q100') construction to a following: h
10.Static water level below top of casing: 7 o C+ (ft.) Divisi of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"t" 16 7 Mail Service Center,Raleigh,NC 27699-1617
11.I3orehole diameter: G• (in.) 24b.For Inlecti n Wells: In addition to sending the form to the address in 24a
12.Well construction method:
26 -a 1?__l. above,also sub it one copy of this form within 30 days of completion of well
J construction to th following i
(i.e.auger,rotary,cable,direct push,etc.)
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Division of ater Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1 6 Mail Service Center,Raleigh,NC 27699-1636
I ;
13a.Yield(gpm) 30 Method of test: 5 Q 1 COY)FA:f4QK 24c.For ter a I & n'ection Wells: In addition to sending the form to
^, x CQ. L the address(es) bove, also submit one copy of this form within 30 days of
13b.Disinfection type:l_.A C . Amount: 3 T 0.bs completion of w ll constmction to the county health department of the county
where construct , j
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