GW1--00090_Well Construction - GW1_20231228

il
WELD CONSTRUCTION RECORD(GW-1) ForIntemal Ilse Only_ �'
sl I.Well Contractor Information:
14.WATER ZONES I
;f WelContractorName MON "ITO I ! DESCRWTION
4 d -4- 77 ft- P I° 11 G
11 NC Well ConhactorCertitleatioaNamber t'O IL a Zi I 141 epin
}I 1E.OUTER CASING(for rnuI&essed was)OR INER(Nap lteable)
II
Dv r jef! Vf i thy IRON 1
/��a/•� i DUI/ RctaaFss xrnl.
Company Name f1 ft: to 1 6 m. SDR-2I PVC-
.WCuConsfrt1CiI0nPerIIlit)�:�l) "�J 16. RCA�SING ORTETBING(geothermal
!! closed-leop)
l'i? tl)# WO HUMMER.. THICKNESS MATERIAL
I, Mstall applicable well construction permits(i c uiC Cot n Start,Variance.etc) ft. 1 1 ' 1 f; .
' 3.Well Use(cheekwelt use}:
ft' 1 j ft in.
Water Well: 17-SCREEN I"I - -
1,i �`Agricultural • FROM TO I DL4METER SLOT SIZE TffiCINESS I Mt1TER
1, *'► nnicipal/Public fl: I I ft. in.
I;; Geothermal(Heatin�CooJingSupply) ;�iBesidentiaiWaterSnpply{single)
14 ft: in.
1;; ' \ •Industrial/Commercial QlResidential Water Supply(shared) ft. 1
I f8.GROIIT I •
I,! 1Irrigation. - MOM TO MATERIALEMPLACEMENT R II(OD&ARM
I; Non-Water Supply Well: 0 'L 7Q ,ff: I/e 1.7rr ?xi'
', tt Monitoring .
1. Injection Well:
�Recavery ft. I I ft.
*Aquifer a K= I P It.
f l 9 EaGrotmdwaterRemediatioa
!' Atlaifer Storage and RecoverySakai g�� 19.SAND/GRAVEL PACSizf appIcabla) '
Aquifer Test
DStonnwaterDrainage i:Rom ft. I ,' ,ft. MATERIAL E(LfPIACER Th3HTHOt
J Experimental Technology QOSubsidence Control ft I l 1 ft. .
I,: a Geothermal(Closed Loop) prancer 20.DRII.LING.LOG(attach addiFone sheets if necessary) •
Geothermal(lleating/CoolingRetnm) flOther(explain.under#2IRemarks)
EROPI n Ntcolor.Lazanrss,sn;umcrccynGezarns;un
11 ft; .ft. SOW Shille- �ir�-
I; .Date Well(s)Completed:1 Z"1 Z-22 well lIl# ft )-e 1 I .
t Sa.WellLocation: ft. ,ft.
Y��WfITG
;:I OOIVilej - c4 if. ft.`-
'.' Eacih /OwnerNamc
l i FacAitgII?11(ifappAcable) ft. ifk' .-
I 'OH wes/ ,he �swgrnp Re Fl, �he�, 2%1 ft-. ' _ 'i : nit,,
P' ica ♦adress,Cttyc`' .r, <�
j.! ,and ft �, ��a R,;;J '
t'n �y
sI� • J5Z39111 21.RE , . _t. 3 & 2g
c)
County . PantelIdentifcation io.(PIN) I III or,-^.1;_,., .,
Sb.Latitude andlongitade in degrees/minutes/seconds or decimal degrees: 1 O`w ''Z '1 ram"a
Cif well frc[d, tRaagissul$cieat) I -
22.Cerftfreatia,=
3C. N31.`l GOG w
6.Is(are)the well(s) Permanent or QlTemporary Signah:m ofCertifred Well r
Date
By signing thin form,I hereby certify that the we (r)was(warn)constructed in ace
7.Is this a repair to an esistingwelt: Yes or co with 1SANCdC 02C-01(10 or'Sit NC4C 02C.0200 Well Construction Standards or.
If this isa repair.Tilt oat lomtm well constrnefipairfornafionand explain the natwe ofthe co.P7(fdligrecark4ttsb artpravrdedta tnetneltowner-
repair•underf-21 remarks section or on the backofthisform, I
1' 23.Site dia
gram I or additional well details:
I1I'i 8.For GeoprobeiDPT or Closed-Loop Geothermal Wells having the same You may use tile;back of this page to provide additional well site details
{' constuction,only I OW-I is needed. Indicate TOTAL NUMBER ofwells construction details.You may also attach additional pages ifnecessary. •
1„ drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth belowlandsurface: I- Q I i
Formulriplezuelfstistallde the(different(�arnple-3(a�200'and2Q10p9 (I) 24a. ells: Submit this form within 30 days of completion
For All W
1;: 2�� const>xtctionto the to
to.Sfa6ewater level below top ofrasing:
j Vf.uuter level is above casing use i" ( ) Division of Voter Resources,Information Processing Unit,
'�/ I 7 Mail Service Center,Raleigh,NC 27699 I617
1! 11.Borehole diameter. G , ' '
�) =24b.For Ini ' ( Wells: In.addition to sending the form-to the address
t,i above;also subink-one copyof this form within 30
14 .12.WeRconstructiion method:Air Rofordays of completion:
( il (Le.nuger;miary,cable,direct push,etc} / aonstruetioniottIhefoliowing
FOR WATER SUPPLY ONLY: Divisionof�Water,Resources,Underground Injection Control Progr
,
. , 1 S Mail Service Center,Raleigh,NC 276991,636
13a.Yield(gars) Method A. r ('LL Method of test:/-Al c I—I r7- 24c.For Water:Saintly&Injection Wells: In addition to sending the:
'e L J,,� ex.. the address(es) above, also submit one copyof this :form within 30 t
f1
13b.Disinfection type: T a t Amount: completion of well construction to the county health department of the
I where construe I •
1' l
s