GW1--00078_Well Construction - GW1_20231228

T___,_
W 1 ' 72 at:t2 . tCTIiO` RECORD (OW-
1) For Internal Use Only: I-----
1.Well ';t t;•:c•rot•information:
Cli(!S Kl'1C) t
Well C,.ru:;:,,ar ';;:ae 14.WATER ZONES I '
FROM TO/ DESCRIPTION
:':C :.eruficauon NumbercJJ J a I 'I —
r1Q a_ :ist, 1 G 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
__ _ FROM t TO I DIAMETER ! TIIICENESSS , MATERIAL
C'cr'r r... .,.....,' 0 fi. 6-6 ft. / //5i in, L/j")12./ P
eye n 116.INNER CASING ORTUtt ING(geotl,ernw!c8l`osed-Ioop)�-- �•
2.Wei)Construction Permit tom) 96� �''�'s23 I FROM I, TO
permits(
Lirr;.,J applicableth/c azll constructionconstructioni.e.WC,County.State,Parlance.etc.) I DIAMETER THICKNESS MATERIALft. ft. I in.
3.'5'ea Use(cheek well use): ft. ft. I in.
),Wia(er SEtcply Weil: 17.SCREEN I !
g:a-`rri�„nit::rth' FROM- TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Municipal/Public it. ft. In.
'Geothermal IHot,tins'CoolincSupply)� "RdsidentialWaterSupply(single) _-�_
.!nat;.:rul:wnta)crcial Residcntia111VaterSupply(shared) ft. I in.
iilirieutiot: 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
;tau-Water Supply Well:
ft. '�]CD ft. !1/1•'dU1 C j_
—iiMonitorinv LRccovcry {�C �►4'i�JS
Injection Weil: it• ft.
aquifer Recharge tt• ft.
iGroundwater Remediation
Aquifer Storage and Recovery t J Salinity Barrier 19.SAND/GRAVEL PACK(if applicable)
' FROM I TO MATERIAL. EMPLACEMENT METHOD
t,.rquifer Test
Stonnwater Drainage ft. ft.
f Experintentai Technology 0Subsidence Control ft. ft•I : ie:ithei;i•a!,Closed Loop) LITracer 20.DRILLING.LOG(attach additictral sheets Ifnecessary) — '
F
E;Gectheri;al(Ileatin_/Cooling Return) flOther(explain under#21 Remarks) FROM I To I DFCRIPTIOR(color,hardness,sail/radt type.grain size,etc.)
q fr, I .3 ft- red t G f a .y
4.Date Wiell(s)Completed://``/ oZ Well ID# .
3 ft. I� ft. !•{ISa9n1'c Roc
/�iC j�
S t.Well Location: C.) ft.•II i� ft. � to ft-- ju I 1�oc
L.)irvdso i ii7 J J �ft. //3 i e L7 121�E 1�:4
Fie;li:yC.,v1:,-\a::it, Facility MD (if applicable) ft. ft. 2^ 4•. n,�
st.
3... .5.—_-� iefttO�fe-ii /! ft' I ft. I v��.r r 4)/
I
Paysieal:`>duc,;.City,and Zip ft. I ft. DEC CO` 2023
1f/- � 21.REMARKS . .
County
ParcclldentiticationNo.'(PIN) (�+„: �.K fct
uYQ/�.3`4y
SO.Latitude and longitude in degrees/minutes%seconds or decimal degrees:
(if well field.ass Icailong is sufficient)
. 22.Genf ica'on:
�. •ii* W _
Date
6.tstare) nu wail(ilt� ,•n''.rrnanent or Temporary Signature ofCoitified ell Contractor 7
Date
Br signing thi.,•.frnin,1 hereby c•erNf r slim the well(S)teus(were)constructed in accordance
'i _'S E.!ii`- t:!?,'),;i to an existing well: 01'es or 'tio with/5A NC.-IC(DC.0100 or ISA NC4C(PC.0200 Well Cons!,,,I,in Sitoulards and that a
11 tin. ;.,:.•_pair.fill ant holm cell conslructioa infinonalion and explain the itaMre of the copy of this reword has hecn.pie vided to ilia bell owner.
n7nur awed-r:2!rr'nruIWs are•//in,nr nit lire line/i of/his•/nrni.
23.Site diagram or additional well details:
S.For GceproheiDPT or Closed-Loop Geothermal Wells having thb same You may use the bask of this page to provide additional well site details or well cans:'I r k ii ' in I (,V/-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
(ii uteri'
3 SUBMITTAL INSTRUCTIONS
4.'1 nria t: I]depth below land surface: (ft.) 24a. Fort
For ic,ririrIe',..its list all depths ifdifferent(e atitple-3(r)200'mid 2(ri,�100'1 nf AA thehello winmit this farm within 30 days of completion of well
construction to following: i
J. radr t;•;it!`t'level below top of casing: 0- ft. -
L'.euir-ter,.„•„b-,i=e resin;.use"+•' ( ) IBivisi®n of Water Resources;Information Pt•ocesslr.;Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
I_.lior'ttuie di:I:me.ter: C (in.)
24b.For Inleetion Wells: In addition to sending the form to the address in 24a
12.`;t.r::eG stre.etion method:, _[ (1, ) above, also submit one copy of this fynn within 30 days of completion of well
is ua ;cd,ra r.).c.dtle,dues:push.etc.) construction to the following:
s Cyii,.r;_ui5 Su PLY WELLS`v ONLY: Division of Water Resources,YI I det•ground Injection Control Program,
• 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: C(f•h T 24c.For Water Sunpl�•&Infection`tells: In addition to sending the form to
the address(es) above, also submirl one copy of this form within 30 days of
- a. .. i--';rtin Amount___ = _ r( /6 Q?� completwhere cons of well construction to he county health department of the cOunty
where constructed. f
1 t
North Carolina Depe ment of Environmental Quality-Division of Water Resources " :- , ,,
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