GW1--00103_Well Construction - GW1_20231228

L .CONSTRUCTION C© (C� 1) ForIntemal Use only.
WELL
1
1.Well Contractor Information: I
I,r
?Ali L
j, ��� vier 14.W.9TERXONES 1 -
Well ContractorName RODE TO I , -I DESCREPTION
Lids A- IS! I83 ,; cruel
NC Weil Contractor Certifkarion Number
Z•�R Z Z I I f1�
4,I �� wen
15 OUTER CARING:(fnrmulti-sedwels)ORLII�D:Cifap 1ieabie) -
I.( t b l Dr 11-101 OM I TO: I DIAMETER I THICKNESS' MATERIAL
I`'' V�vJ Igo ft. G In. p pvc
. Company/lame .-
I; t 16.ReartcrsmIGM ITRINGffeothermat closed-la col
2.We11ConstructionPermie#: U I t IRO I TO DIAMETER r THICKNESS I >v�A�RIAL
I, List all applicable nsfl constructionpermits(i.e UIC Coinzw,State,Parirmce.etc.) ft I j ft. in,i
1 1 i 3.Wall Use(chesirwelf itse): ft.
I ft. in. I
?j Water•Suppiy Well: 17.SGRE1 I - - -
I
I FROM TO ' DIAMETER SLOT SIZE THICKNESS MATER
•Agricultural • a •..icipaf1Public ft I ' f. in.
i, -Geothermal(Heating/Cooling Supply) krdi•..idential Water Supply(single) fa ft in.
}'. • ‘ I'Induslrial/Commercial EDResidential Water Supply(shared) is.GROIIT I
1, irrigation - FROM • TO! MATERIAL EMPLACEMENTMETKOD&Aht
i Non-Water Supply Well: 0 ft. ZO it- fC/)/ Dry Pour
I; . " i Monitoring DRecovery it. ft
'' Injection Well: I
it I ; ft'
IA9 Aquifer Recharge OGrouadwaterRemediation i,; Ill Aquifer Storage and Recovery Salmi Barrier 19 SAND/GRAVELPACS{ifappficable)
i i y PROM TO MATERIAL EtYFPLACE1riENTMEFHOL
it Aquifer Test OStormwaterDrainage ft. I ! 'ft,
1
I $Experimental Technology . OSubsideuce Control fL I ' ft. -
•i Geothermal(Closed Loop) OTracer 20.DRIi.LINGLOG(attach addiConalsheets if necessary) -
i; ••Geothermal(Ueating/CoolingReturn) ill Other(explainunder621Remarks) PROM Ta DESCRIPTION Cmlorbardacss so�tmektpp�ar,;aS;,R
�'; C1 ft �3Z it, Sa Ovcrburcen
4.DateWell(s)Completed:fr 23 Wed DM 5Z ft' *1i5 it
I I r-1 � yj'jrAt7rk i OtlAt'&
5a.WellLncatioa: ft I I It.
jtinalcI Cnc Mullis ft I r t::.� rr.;-
1 Faciity/OwncrName FaclitylDit>tapplicable) ft. I : ft °
Zcli ff i•ve r Hilt, rid Ift D .
�. �Ul
Physical Address,Cry;and Zip it I it
�IP l �s Z 11 o rook In°.:rr -. Jr.` f 1..
I' _ Coenty . ParcelldenrificationNo.(PIN) • I
5b.Latitude audlongitude in degrees/min•
' or decimal degrees: '
'% (if well 6c�d, alReagissufHcieat) I '
22.Certifir
Ii 3G. 323'_ �l , K�Iqd
I _ �' ` � f-2✓523
f.j 6.Is(are)thewell(s) rmanent or �ITemporary SignaturenfCettifii edWell� Date
j By s lag—thisfornr,I hereby certfy that the ua11(r)was(Were)constructed in arc
It 7.7iSS this a repair to an.existing well: .Yes or withlSANCCOC_OIODorISANL`riC 01C.0200P/eIlConstmctlon Standards or
i,1 Ij'This.is a repair,fillour b town well constrrrelioiinformatron and explain Me naru a ofthe roPyofgammahas beenpravided to thelvelFowner_
repair under 2Iremarkssectionoronthebackofthisform. I
23.Site diagram or additional-well details: •
1: S.For Geoprohe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site detains
' construction,only 1 GQV-1 is needed. Indicate TOTALNUMBER of wells construction de hails.You may also attach:additional pages ifnecessaty; -
I drilled: '
�/L SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 l� . (ft) j
{ Formuf plewelLstfstalldepthsifdfffercrtt(example-3(r+ QD'and2fa i00) 24a.For Ali Wells: Submit this form within 30 days of completion
constnlctiontoilMfollowing: .
i'` 10.Stolle-water level below top of casing: kr (ft) Division or water Resources,Information Processing Unit
;' •.Ratter level is above casing use"'-" r g +�
l� 1 1 Mail.Service Center,Raleigh,NC 27699-1617
I1.Borehole diameter: ' (in)
%Z4b.For Inlet• n Wells: In addition to sending the fotm.to the address
above,also submit:-one copy of this foto.within 30 days of completion! .12.Well construction method: rf rRattgrycdmstrnctionto a-
foliowin
- fie augerymmty,cable,direct pusb,eta.)
FOR WATEI2S[7PPLYWELLS ONLY: •
Divisionof�Pl aterResources,UndergroundInjectionControlProgr
1636 Mail Service Center,Raleigh,NC 27699-1636
'; 13a.Yield(gpm) Method of test: 24c.For Water Supply&Infection Welts: In addition to sending the
I! the address(es)(above,'' also submit one copy of this form within 30 c
13b.Disinfection type: Amount:_ completion of II construction to the countyhealth f t, wherecous'fruc department of the