GW1--00102_Well Construction - GW1_20231228

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•WELL CONSTRUCTION R CO CErW--1} Forintem�lUseOnly: ."�"
,, 1.Well Contractor Information: 1
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"I DESCRIPTION
ellContractorName
Ltd -A- I/rj li tJ'
NC Well ConcorCecnNber a 1
(i Dv 5
1.1 is.OUTTR CASING(formal&c�sed wells)ORZiN);It(if nP ilcable)
W � ��l��l t �l� MOM f� I T O. I DIAMETER THICKNESS IYIATEitiAL
i.
i; Company Name J Q(0 V bict In- 1 5ASDRa)� PVC_
2.Well C:onstrucliO4 Permit#: /( 387 16.II RCt1SING MUDDING(geothermal closed Loop)
FROM TO DIAMETER.. TRIMNESS ( MATERIAL
,; List all applicable well constructionpermits(I.e.UN,County,State,Yatiance.eta) ft. I ! ft in. If
1
it 3.li eII Use.(chealrweRitse): it. I j It. iu
,; Water SttppliWell: 17.SCRL'ID I-I • - .
110Agricultural VunicipalfPublic PROM TO ; DIAMETER SnOTSRIE THICENESS M TEi2ft. I ftin.
Geothermal(I�eating/CoolingSupply) sidentialAFaterSnpplp(single) fr.
,
1° Indasttial/Catnnicroial QlResidential Water Supply(shared) I i ft: in.
18.GROUT 1
1' I1Tigatloll FROM TO. ` MATERIAL EMPLACEMENT METHOD&Arse
1; Non-Water Supply Well: O fr. OD ft"
1k j PCCi`l' .
Monitoring oRecovery ft, I 1 ft.
Injection Well:
II, Aquifer Recharge DGroundwatcrRemediation I I ft.
39 SAND/GRAVELPACS{ifappllcabie) '
I'i Acluifer Storage and Recovery °Salinity Barrier moat - TO MATERIAL EMPLACEMENT METROL
;I
Aquifer Test DiStouuwatm Ihainago ft. I ( ff.
j Experimental Technology • OiSubsidence Control f. I ' ,it.
, Geothermal(Closed Loop) DIiiacer
20.DRILLING-LOG 3G(attach a ddifioaaI ahcets ff ttecessury)
i 1 —Geothermal(Heating/CoolingRetum) (Other(explainunder#21 Remarks) mall xO DESCRIPTION Ccclor•hardams so-Wroth type.grain size,
i o ft: D It; rr-b J
} 4.DateWell(s)Completed: 3--a..- We111D# 7c7 ft r ft eitctc; �y`atjtY�e
Se.Well,Location:,,��yy�� ft. ft.
I!i Jc�c9�►/le !•`c:Brays/` ft r"-: `� — _.
li
lactLZy/OwnarNama FacilitglI}.t(ifapplicsile) ft. ft �'�.i...,,'` it y;
i Physical Address,Cityt,Had p ft. it. "d - 4GLJ
Ashe 11(11 5•as6 21.E . r� ::�,npf-nrs ,,,__.:, -
County . Fenzel ldentifrcatioallo.(PIN) I L%' `vh jt�vfa a Lr,,;
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j; Z./Altitude and longitude iadegrees/mianteslseeonds or decimatdegrees: i
Of we
• llfict ,aE,tpt/tongnsufcient}
II dK/c i 22.Certifieafi I o:. •
36•Lf0e7316. Ifk1,31� 67 W
G.Is are the wells en manemt or p nary Signahue of Certiffed.Welt r
. Is(are) () P �'tem o s Date
i; By signing rhieiom%I hereby certify that the uwll(s)was(were)constructed in arc
7.Is this a renair to an eaisfingwell: E.Yes or ONO with lSANCftC 0�2G.QIQQ or l SANC4C 02C.0200 Well Construction Standards ar
!i If thisisa repair.fill oat Imam well construction lnformatlorrand explain the nature ofthe copyofth c d llwsbeeaprovided to the meft'owner-
repairamderf2l remarks section or ea the backofthisform. I 1
f 23.Site diagram or additional well details:
;.t I.For GeoprobefDPT or Closed-Loop Geothermal Wells having the same You may use tile'6ack of this page to provide additional well she details
f' construction,only 1 GW-i is needed. Indicate TOTALNUMBI ofweIts construction dells.You may also attach additional pages ifnecessary. -
I i drilled:
S]BMITTALIIVSTRIWCTtIONS
1,1 9.Tot ( )al well depth below land surface: �� �.'For All Welts:.' Submit this farm within 30 days of completion
' For mutipfe wells list aft depths ifd8erent(=ample-5@20n and2ajloo) constmctiontothefollowing:
l' 35'
10.Stalk water level below top of easing: ( ) Division of Water Resources Information Processing Unit Ifitater level is above easing,use-- ? $ y
1 r 7 Mai Service Center,Raleigh,NC 27699-1617
11.Dore hole diameter: 6 J
flan ?fib.For Infection Wells: In addition.to sending the fortn.to the address
.12.Well construction method: err i a t�f a60ve,also seb)nit o$e copy eI this form within 30 days of completion
`'; - (ie.auger,'Mary,cable,direetpash,etc.) ✓ consttuotionfi t'Itefoliowing
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''' FOR WATER SUPPLYWELLLS ONLY: Division oI Pate Resources,ilndergroundln jeetion Control progr
1636Mait Service Center,Raleigh,NC 276991536
13a.Yield(gpm) Y Method of test: .cif' L-CA` 24e.For Water I annuls,&Injection Wells: In addition to sending the:
t !, the address(es){above, also submit one copyof this form within 30 t
1 4,; 13b.Disinfection type: -tT Amoant: {E2 a• .— completion of well construction to the cou health department of the
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--where
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