GW1--00086_Well Construction - GW1_20231228

For Intern ;lase Only: -
1.Nell.Contractor Information: i
Well ContractorName N — 14•WATER ZONES I
BLOM ITO 1 ' DESCRIPTION
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(L Z; 5
NC Well Contractor I �� - (Qb�
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Certification 3btS L J-g tt:, e
A
O f f,r 1 I 1 'OUTER_CASING for mute w.ed;.ells ORLINER a..11cable -
! 1Rohi
Company/lame" ' J D TffiGIffVPSs
! ft 1tAIERIrtL
2G� 60 in. SP -2/ c._
.I( Z.Well Co ttcjonperI�t#:J I��04q lfi•10WCAEINGORI'EIBIZIG. _-.thermal ctosedtoa.a
. k List all applicable well construction permits(i.e.TJlC Comm State,Variance,etc FROM IFO nt�zrl tR TmC SS MATERIAL.)
I 3.Well Use(cheslfwelCuse): I I ft: in.
ft. I ft. in.
Water Supply We :
i1 Well: V.SCREEN'II i
Agricultural nnctpajpubliC t?ROit3 TO i2tt..rrr�rr t ti SLOT ME
C-eothetmal(l eating/Cooling Supply) ft: �� in. Tess MATES
PP y) identiaEaterSnpply(single) 11111111111111111111
�„�IndnstrialjCommcrcial Fr' in
�1Residential Water Supply(shared) EIVI Irri tionterSnpplyVEFell: l8.GROUT I I
i�Tlron °M To 1••;:ara•t vj EMPLAcEmE TMETHOD&Ant
Monitoring tO ft. et-
c% 'cm
O
InjectionIIIIUIMMMIIIIIIII
Well111.11111111
:
�ReCovery
ti
r Aquifer RechargeDGroumdwateerRemetliation
•j Aquifer Storage and Recovery F�Sakai SAND/Gli 4%TEL PACK'(tPn a Lr
Salinity anamauttRonr •
Aquifer Test TO
h7AtEErAL EafPLACEniENTtKETtiOL
;i StomzwaterDrainage
Experimental Technology SubsidenceControl
Inallitillallinill
Geothermal(Closed Loop) D►Sub orracer
Geothermal 20.D
�: (Heating/Cooling Other(explainunderi;'?1Remarks) miv' CMG{attaehudditianatsheetsiineeesssry
To I DESCRIPIIONfader.banta
/�, ft ess.SoiU a �Elmraclt n �
�; .DsfeWeU(s)Completed: a Z�, Z 3 Well DV �--'.� i i
t it Pal"
MiliffLei h+on l�ctall�n ONO `�" `f�1�I facility/Dwncrwamc
FacilitylDh(ifapplicable) ft 1 I !, It
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t f CG4" C {-G
Phi�icelAddrms,City,and Zip .� k ,q' y�'*
�.1. ash e �� : . t .°i
County
!I i - Parcel IdentiacationNo.(PIN) I1 I ! In;br�.,•<;.,
r 3b.Latitude and longitude in degrees!n;<intttes/seconds or decimal.degrees: I ^ ?:v1 (iftvcll r7Cld,era laUlmgis sufficient)
jy�,; ,
�' 3G.37 ' 353" N !35-0g06 2 ?2.Cet ti8ca
l W � .
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!;! 6.Is(are)theweII(s) rmauent or ✓ �'��1 j' ITemporaty Signature of Certtti Welt r
7.Is this 8 repair to an eSISYIngIVeII• yeS or NO By signing faor I,her7eby certify that the waft)was(were)•constructed in ace
if this isarepair,ft out Tarawa wall construction ormatiotrrmdr lSslhIC�YC 03C�.alOd or lS�1NC4C 02C.02QO Well Cansrr,rcrion Standards or.
`- repair under lremar'ks section or ors the backafthisfarat � thenattrrnaft/ie FPofttrisrernrtLhosbeptprovidedtothen2FFmvner
11
23.Site diagram dr additional well details:
I i I.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same may use the do of thispage to
construction,only 1 GW-1 is needed_ Indicate TOTAL construction de
pp ER ofwelts r, aprovide additional
well site details
:I (,( drilled: -1 ;You may also attach additional paves$necessary.
li. 0 SJ1L3 ALIlVST UCTEONS
t' 9.Total well depth below land surface: 3 70 I
"! 9For.T otatiple well
depth land
s rear(example 3 ? (ft) 24a.For AB Wells:
a> oo'and2@Fop3 _ Submit this fnnn within 30 days of completion
}111 10.Stadewater level below top of casing: "1 Cottst[ttctionto rite following
7't Iftsutpr level u above casing•use"t^ (ft) Division fWaterResot>tees,InformafimProcessingii
F II.Borehole diameter_ G r/� I51? Berates Center,Raleigh,
j„ (in.) fib,ItTC2?69916I7
j,; I2_Well construction method: j '-24b___ Infection Wells- In addition to smile the forum_to the address
1 (i e_augeymta Club above,aso submit-Ione copy of this form within 30 days of completion
l 1 ry,cable,daactpusi,eta) r constructionto thiefo�howing:
i 'I FOR WAXER SUPPLY'WELTS ONLY:
Division of Water�R I winces Underground
I „ ( , ergroleigh,eetio>F Control Pragr
�j p (� 1636 Mail Service Center,Raleigh,NC 276991.636
13a.Yield(gpm) Method of Pest: I' Lt't I
24e.For Water Sapniv r Trieedon ells: In addition to sending tine:
Si I36.3}isinfeetien tgpe: Amount= the address(es) above, also submit one co
t completion of well oastFuc copy of ibis 3h c
tion to the county health department
tment of the
{ where conskacbed. i
,! '± + .