GW1--00087_Well Construction - GW1_20231228

WELL CONSTRUCTION RECORD( 1) Porintemal'Use Only: "" .la':
ii 1.Wen Contractor Information:-• { I
Pai9 L PD f/112c I
14.WATERIZ0Nes I
Well Contractor Name FROM I TO I ' DESCRIPTION
i
d ' " 2� 110 P . Ic,cJ. 3c h ; .�,5,.,
NCWeil Centimeter Ce ifcadoaNumber ___car
,. rc+nac..kgues�z -• 13.70%
Il IS.OI TERCASING(fornod&-cbs was)ORTMER.asap IIrnble
li
Oozy 1 �1� a�►Il��� _ .TO. DIAMETER 5 MATERIAL
Coma Name th "2ICP nYInLT S
1 CO 6
16.mm:comt;ORTQSIDI .{geothecoaal closed loopl
3 Z.Well Construction Permit#:3gl�22
' MOM I O f' MAMMA TH :NESS 1 WINIERIAL
(I List atl applicable mail construction permits(i.e.VIC Canng;Stare,Yatmaee,eta) It I ft. in.
I
;i 3.Wleli Use(ctteskwelt use):
i I I
Rater Supply Well: 17.SCREENI"I - - - -
t I Agriculturala t FROM TO` DfAMETER SEAT SIZE THICKNESS MATER
' 'cipat/Public ft I i ft.: is
4. •Cseotltetma!(Aeating/CaotingSupply) ; Rcsidential�DflaterS;uppiy(single)
ft.Tndnslrial/Commercial I ' in. r
°Residential Water Supply(slated) I$.GROAT i
Ii . ;IItrgati6II -
FROM ITO MATERIAL EMPLACEMENT &Ate i` Non-Water Supply Well: 0 ft 120 ft. 3/ssHale Rut Four
*Monitoring EIR.Govery
rt. I ft.
•
Injection Well:
' II•quifer Recharge DGroundwatecRemediation ft I I '; D' •
Aquifer Storage and Recovery �ISalinity Barrier en SAND/GRAVEL PAG7£`( xrg cable) '
� ODf TO MATERIAL ENfELACEi1iENThFETHOL
oiler Test UR
EIStotmwaterDrainage ft. I ft.
:, 1 Expciimental Technology QlSubsidenceCanuo) I f8
i,j 1Geothermal(ClosedLoop) DITracm 20.DRY[;LINGLOG.(attach additionalstreets irnecessaiy)
it Geothermal -eating/CoolingRettun) $iOther(explainunder#21Remarks) FROM DESCRlPTtarttwt r.Laraaess sniuroctctunaet,;II,
fize
ft ft
�€.7}ateWelt s Completed: sot
j () p ! "�� Z'' Well ID# SZ, ft. :fr. � r
aa.Well Location:
ft. I
YI r/bl�tCl C �e l�lni�e
1
I! Zcchary Muty I ft
I.! Facility/OwncrName Facility A} (if applicable) Ift.
f F1•�{- Horse on L q rt 36Z Rid e D,we-tJ6Ffeen I 1 i ft., ''' - ' �g�F r.*:-,
Physical Address,City and Zip 2809y ' ft: I I ft' D - '. w."'
` CtLP
she • Iq 22707 z 21.REMARKS ; - , b Z�l.7
• County' - ParcelIdenti$catiottNo.(PIN) I ln;Cr, �iC
i Sb.Latitude and longitude is d I { IJW ,r8: 'x ,p !egreesiminnteslsecondsordecimaldeees. J.�
1.• . (ii€wcllfi llil ctd,pat/ongissufcient) Certiffratm a1:
I' 3(.3ii Z2 c N - V I .l'1°t 239111 W y,--
cace,
! 6.Is(are)the well(s) r-manent or El/Temporarysignature of[krtified Wall{c Date
i gYsign►ng this AIM I hereby certify that the well(r)was(ivere)-constracted to ncc
7.Fsthis a repaia•to an existing well: ales or El< with 154 NCAC 02C.0100 or ISiANCIC 02C.0200 Wall Consirnction Stm duals as
0 ifhis.isa repair,fill oatknawa well cotutruaioranformntion and explain rhe nature ofthe CoPYTthis reel fasbeenp vide totheivelf owner-
repair rwtler a2l.remarkssection or on the back ofthisform. I
23.Site diagram.or additlonai well deta17s:
(, S.For Geoprobe/DPT or Closed Loop Geothermal Wells having the same You may use the;back of his page to provide additional well site details
construction,only I sCW-I is needed. Indicate TOTAL NUMBER ofwells construction deilai7s.You may also attach adrfitionai gages ifnecessary
i I chilled:
•
SUBMITTAL DISTRUC£IONS
I. 9.Total well depth below land surface: S�5 I I
FormaltipfewellslistaudepthsFfdifferent{example-3(a)200'and2Qi0p') - gt) 24a.For All Wells:1 ntmit this form within 30 days of completion
I I coastmctionto the following:
l; 10.Static water level below top of rasing: 3 1c� 1
Ifunter level is above casing use=^ (ft) Division of t Pa _ Resources,Information processing Unit,
i j 1 71Ylai1 'ce Center,Raleigh,NC 27699 lti 7
21.Borehole diameter.l7 0114 24b.For Iniec(ioit Webs, In.addition to sending the form.to the address
above,also subinitarecopyofthisformwithin30daysofcompletion
`' .12.WeII construction method:f�V.r- la'N(y
I;r - (Le auger,mlary,cable,diiectpasb,etc.) ConShIICltolttoLlhe'foIiowir
'.. FOR W.A :R SUPPLY WELTS ONLY: Division o Ptr'R iteeso�ces,Underground Injection Control Pragr
Licit-
1 � 1G36It3aii Service Center,Raleigh,NC 276994636
132.Yield(gpm)�� Method of test; t L, I
24�For Water Snout,'
�e Iniecliau Wells: In addition to sending the
i , D Z the address(es);above, als submit one copy of this form within 30 c
13b.Disinfection type:H 4i n . Amonnb completion of Ngef constn eticn to the county health department of the
i' where constmete'1 1
C;I I '
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