GW1--00092_Well Construction - GW1_20231228

II WELL CONSTRUC`1fiON RECORD(OW_ ) For Internal Use Only: ` •
1.Well Contractor Information:
I:' !j( i 9 L ptai�J��` z��vA zor>zis
11 WelContractorName ..
FRobt= ITO ! ' - DESCRIPTION
L0 A- IGZ ft. J ti Iil. 3 6
NC Weil ConhactorCertiftcatioaNumber
Z57 Oel I ?Gpr l
��1( 15.OUTERC+ASINGgnr'mnt&�Sedwelts) RUNEROfap IIcaMe) -
Ii 00by 15 wen! Of'i II)Al TROhT ore , DIAMETER , THICKNESS MATERIAL.
!1r Company Name 41 • ft: I CG I l] - 3/ -z i ?VL
i LJS��YC 16.I1k'PIERCA�SING ILTD ING(ReatharmalcIosedIoop1.
2.Well Construction Permit#:I-1 0/^I D I PRONE HO , - DIAMETER THICKNESS MATERIAL
I!I List at!applicable welt construction permits(Le.IBC Counts;Siam.Variance.etc) €t. I I '£t; in.
it
i. 3.Well Use(cbestrwelfuse): I ft. I ft. in.
' Water Well: 17.SCREE I ! " • . - . .
FROM To DIAML+•rER ELOTSIZE THICKNESS I MATER
_ Agricultural §1,1 ..,,'cipal/Public ft. I ' ft is
i Geothermal(Rcating/Cooling Supply) ;�Rcsidentiai Water Supply(single)
ft: I I ft in
Industrial/Commercial DResidential Water Supply(shared) A.f OQT
11, — Irrigation. - SROM TO MATERIAL EMPLACEMENCr amnion&AM
I'! Non-Water Supply Well: 0 `? ft renlenrle Pfy f06p•
i.i Monitoring EiRecovery it,
Injection Well: ft• I I it:
Ili Aquifer Recharge DGroundwaterRemediation I i
j AQuifeI Storage39 SAND/GRAVELPAC1f{IfapPReable) - -
g Recovery 0SalinityBamer PROM - TO. ` MATERIAL EMPLACEMENT METROL
I: Aquifer Test oStormwaterDrainage ft• I ; ff.
,'I Experimental Technology • DISubsidenceControl ft: I I •
I,; - Geothermal(Closed Loop) i lTiacer 20.DRILLIlYGLOG(attach additionalsheertsa
Geothermal(I1eatinglCoolingRetum) rlOther(explainunderV21Remarks) mall TO nFS£RIPTIONIcalor, ardatifnecess n)5sso0tmektvp4grain
(( u a ft cg. ft , plri-- San)
4.DateWell(s)Completed: l2'I 1'Z 2 }NeItID# ,it L3 , 9runif
�L e/ 1/ lesf
3;Ov
Sa.WellLocation: ft I it:
i'
Ralph i'. a 1ph •�/yjj ii) • _ It I 1 Ifs:
I' FactthtyOwnerNamc Facility ID#(ifapplica6le) f I off' r —• ..
IOl Park ut Pont Dr Wes}-Je •en I • 't -- :-°v y
Z 9y --,:z..ie
!i Physical Addtcss,City;and Zip / f ftI .ft. J
Count); . ParcelldentificationNo.(PIN) ( r..a.� `' `:7 I i
'' •
I ; •�JJL•iS
• SIT-Latitude and longitude in degrees/minutes/seconds or decimal degrees:
,{ . (If weir fiord,riA tttangis cumcieai) �.Certificate,'
i 6.Is(are)thewell(s) ermanent or OTemporary SignanneofCertifred.Welt or Date
c1
By signing this Arta,.1 het'eby certfy that the well(s)war(ware)constnected in acc
4 7.Is this a repair Tosnexistingwell: O•31•s or O withISANCACd2E.oioo ;SrLNCtiCO2C.0200 Wall Convn,aionStandardsor•
f; If this is a refrain out hnnwn tvell consttuclitm lrJormntion and explain the natureafr/re CD117 re s beenpravided to the:veltowner-
repairuntlerti2l ranrarlis section or on the backof:hisfartn I I
23.Site diagram or additional well details:
• S,For Geoprobe/DET or Closed-Loop Geothermal Wells having the same You.mayuse tl;a(back of this page to provide additional well site details
I construction,only I GW 1 is needed_ Indicate TOTAL.NUMBER ofwells constraetion details.You may also attach additional ages ifnec
I
pages essaty- -
drilled: SU13MlTTAI,I
,' IINSTRIICTEONS
I 7,�.
9.Total well depth below land surface; Soo - (ft:) 24a,For All Wells:1 Submit this four within 30 days of completion
' For muitiplewettslistoil depths ifdifatent(example-3a(�00'and 2la]Z003 cons npg°IltD�hefoliowing: P
t 10.Statiewaterlevel below top ofcasing: (ft.) DivislonofjWaterResonrees
(1; •if.unter level it above casing use-yr a Information Processing Unit,1; t� 115.47 Mail Service Center,Raleigh,NC 27699-1617
. I} 21.BorehoIediamPtpr: (2 (m)
'•?flb.For Infection Wells: In.addition to sending the femur,the address
i' 12.Well construction method:A1 f` y above,also subinit-one copy of this form within 30 days of completion:
- (ie.auger,mtary,cable,directpusb,etc.) // aonstractioniv i efoTrowina
Divisiono ater,Resources Und
FOR WATER SUPPLY WELLS ONLY: , : ergronadl�ection Control Progr
lt3fNlail Service Center,Raleigh,NC 27699 3,636
A 1-6- L1 .*
13a.Yield(gpm) I(a f/ Method of test 24e.For Water Supply&Infection Wells: In addition to sending the
rI �/ oz the addresses)`aliov, also submit one copy of this form within 30 c
II `I3b.Disinfection type:.t -
Amount:_ completion of Well construction to the county health department of the
where constr rcttd,'
Iii