GW1--00097_Well Construction - GW1_20231228

I, CONSTRUCTION`ION RECORD Ems` 1
�orlaternaZ vs�o�ty.
?; 1.Well Contractor Information
1
Well•
ContraclorNazne / I' WA,CERidONFr,S I ;
MOM i TO I • DESCRMION
NC Well Contractor �>�0 IL r init! `!"Qt71 - O a
Certification -
i �© t j r 1 1�1 °MEI: ARM-for mule r. is"wells ORTDIE . ,,,amble
3; t
ERIAL
TO MUSTER TEtCSNL55
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j CompottyrName in. hE17
lj' 2•Well ConstrttetiollPerllutt: 3 P 5 2.31
16c sING OR ,
Mgt-all applicable well construclimt permits I TOStk+t�.f: 'e�Irlosed 20 ,1
! ; tar�Farranr8 ercj If. Drab Tmt tQ�SS I►IATlRi4y
vI 3.y ell Use(checkwell:use): in.
Water Supply Well: 1 ! 'm
€�,�,� 27.sCREIS[Y N
AgtiCrtltara! V1amctPaill�tbliC To )}nr•�,;re►a rm.;
Geothermal(Mating/Cooling Supply). ��= Mrs
g FP I`) '�den6al Water Supply(singiej ®�
• . In dnsEtiaVCommcreial cfltesid�fial Water Supply(s7lared) in. _�
I Irrigationis.GROUT i®
Non-Water Supply Well: EOM OM
s = EMPLACEMENT METHOD&AIVI
Monitorlog
IuMectioh Well; Recovery 0O It. �>? r 2 ,
3 t uiferRecbarg
t; GroundwaterRemediatSon
lRgniferStorageaIIdRecavery �t$alinityBasier 3s oANDIGRA'YEI.PACIEfifay;noble
Aquifer Test mom TO ,
`' DStounwaterDrainage t p ft' �trAt' nmxi o>
;, Experimental Technology • QlSubsidenceControl
j !Geothermal(Closed Loop) �1Tracer
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�Cweathetmai .eatin 2a.DRILLINGLOGfatrachadMaoarsheetsifnetessary
1Coo1ingReEItFII) (�©therCexplaiaunder#1Remarks� &itoM ! DFSCRiP1TOM[cu[ar,•:idnesxsnivmetc .qa s
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! .3?ateWell(s)Completed: "��23 1��. Ignaliff
Well ID# Z ft. I iNft
Sa-Well Location: ore / Q��r
GUS1vmer fks n Ict s [nC.
'' Facility/OvincrNemc
Facility II> (if appficabie) MillaRM
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PhyslcatAddmss,City;and Zap > u
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fhe� 523935 �20 ,.
I 'C ParcelIdentibeattoaNa(PIN)i:.
9b.Latitude and longitude isdegrees/minutes/seconds or decant!degrees: F
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iio:l 7.>SStItI3 8 repa4r to au existing�vellt Oyes or By signingIhis,form I hereby certify that tha trell(s)war(were)•constructed in acc
S phis isareoalr O with 1 ibisreCOtC.0100 oJS4N( C D2e.11200 iYeii Construction&tandnrdsar
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23.Site diagraM or additional well details:
t; S.For Geoprobe/i}pT or Closed-Loop Geothermal Wells having the same You may-use the track of this page to provide additional well site details
construction,only 1 GW-1 is needed. Indicate TOTAL NttIV BER o€welts construction del,Moil may also attach additional
?' drilled:
1 I? '; P�'�ifnecessary.
`' S SLFS LTTAr INSTRUCTLONS
9.lrotal well depth below land surface:
`, Formaltipleivel tall depths m1 surface:
(example-3 24a.For All�Q file•@20O'and2Q1OO9 tom) Submit this form within 30 days of completion
I ' IQ Ste eater Ievel below top of casing- 90 conshnrctigato t$e'fo:ioWing;
p !
.I " -"maw level is above casing are"•L" ( ) 13iVi6i0II of 86rater Mesa 6 Ic/ Resources,Information Processing Unit,
i I1t_Borehole diameter: D 1 �jfaFl3ervice Center,Raleigh,
(m.) nil NC27693 I6I7
l '•24ib.For Inie '44reRs: la addition 24 sending the form.to the address
: , .12.Well construction method: 1 f Q
± G far
above,also sa,„;.one Cwa:auger;miacy.,cable,direetpnstyl camstructiontotI�e oTtowm y�this o 30 days of completion
a Iw
I; FOR WET SUPPLY WELLS ONLY:
Division.oi W I rResources,Underground I�ection Control Progr
23a.Meld m [' 1636 Service Center Raleigh,
1 , ' ) 3 NFethod ones• / ���� l i gh,NC 276991636
j 24a For Water`Supply&3niec6nn t�v.,n
3Sb.Disinfeetiaa e. I,t OZ the address es arrow also' addition to scatting the
:' tip AmoQn 1,J completion( ) ,IL 1 e, submit one:copy h this ar
f where coa4oac construction to the county Health depart the