GW1--00112_Well Construction - GW1_20231228

WELL CONSTRUCTION RECORD (GW-1) For internal L se Only:
1.Well Contractor Information:
Ft bSC'-3\i`1 14.WATERZO Hs I
Well Contractor Name
FROM TO DLSCRM[ION-
r�
C5 a. RI j--ft- I Ho floc."..)
-- O CI -+_ t" IL r © f t- �o 1(o lit..)
NC wen Contractor Certi6cotiauNumber IS.OUTER CAS NG for multbenscdwenn OR.LINER fa.-Umhtc
'{1 yf` A ,t 1 ( n�•..^ 17tURt. TO DIM:WT. ER THICKNESS MATERIAL
l t K..-V` ,�.`-/3 1... ft, ft. in.
Company Name
` V e1 �y , 15.INNER CAST GOR TUBING(geothermalclosed-loop)
2,Well Construction Permit#: e cat'3 " ( 0 ri L'IWM I DIAMETER. ITIICK s9 i W,,TERtAL
List all applicable well construction permits(i.e.ti1G County,State,Variance,eta) 0 ft. - r"ft /__ 2c-tn ?D P Z r`
3.Well Use(cheelovell use): ft. ft to. ✓
Water Supply Well: 17.SCREEN I
111 FROM TO DIAMETER SLOT SIZE TTITCKNESS l MATERIAL
Agriculturni 0Mu. oipat/Pubtic n. 1 rt. ' In.
MilGeothermal(Heating/Cooling supply) It'esidential Water Supply(single) ft. l ft. i la.j
11IndustrialiCommercial jResidcntial Water Supply(shared) +r t
l0.GROTIT t
®r Irrigation FROM TOl MATERIAL EMEACE11P.tiT METHOD&AMOUNT
Non Water supply Well: - 6 rt. c 1, rt. e ►Zc fP if�I _
l�aVlonitoring l�-Rccovc Q
Injection Well:
rY il< ft, C�'�
rt. ( ft.
II Aquifer Recharge EDGroundwatorRemediation 1
Aquifcr Storage and Recove 19.SAND/GRAVjEL PACK Ofapplicable)
t3 I[ (SalinityBarrier FROM Tot MATERIAL Er 'iACE arrMS:THOD
iAquifer Test ;-_ Stormwater Drainage ft. I ft.
Experimental Technology OSubsidence Control ft. ` ft.
NUGeothcrmal(Closed Loop) Tracer 20.DRILLING r-{jOG(attach additional sheets if necessary)
NI Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM xot DESCRIP ION(rotor;hardn ,son/rock type.=In sue,etc) I
0 " 5' C hardness.agy/e hue -i 1
4-Date Well(s)Completed: ).-1—LI- 2-3 Well ID# j fL I rX`-/r ft. rot Cr
sa.Weil Location: ft s.
2L4 67-1 fi-o1 ells LL C t ft.
Facility/Owner Name �1 Facility IDfk(if applicable) ft. It.
I It r )u.a.1 ct Sr,r i Il I POI( cep eaui - �. , ,
fU f:-
Physical.Address,City,and Tip 8'1 ft. ft. -'' 6.- � -'' ,
' lr\C riy,,c-.6z 7'j 35 1 i l! i OCR)6 ZI:A:EMARKs. Dp r 9 C. ' `�'.�" W
County Parcel IdentiticatianNo,(PIND ln,,,-,_...•; ~
. .
, ab.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (�i -: - '' i
(Ewell field,one lat/long is sufficient) 22.Certiticatiou. ,
t
ZS.° Lit?'155 7491.8'siv �° t cp, a5 col gr 'l w . -2.________c _
6.Is(are)the well(s)t''ermanent or Temporary tune of Cettili Well Contractor Date
By signing this fo ,I hereby ramify that the wells)was(were)CiNlertcted in accordmtce
7.Is this a repair to an existing well: 0Yes or jNo with 15A NCAC 02 .0100 or 154 NCAC 02C,0200 Well Constrrcxon Standards and that a
If this is a repair,)ill'out known well construction information and explain the nature of the - copy of this record as been provided to the well owner.
repair under 021 remarks section or on the backafthisform.
23.Site diagram or additional well details:
You may use th back of this page to provide additional well site details or well
8.For GeoprobeMPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction data s. You may also attach additional pages if necessary.
drilled:
9.Total well depth below Iend surface: e2 ql--
(ft) 24a.For All Wills: Submit,this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Qa 200'and 2@100) construction to following: P
10.Static water level below top of casing: 0 d (ft.) Divisio of Water Resources,Information ProcessingUnit
If water revel is above casing,use"+" 16 7 Mail Service Cen ,Raleigh,NC 27699- 7 r
11.Borehole diameter: CP.2 c (in.) 24b.For In ee n Wells: In addition to sending the form to the address in 24a
12.Well construction method: 62-0 1- ,(?f above,also subn it one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to lb following:
FOR WATER SUPPLY WELLS ONLY: Division of I ater Resources,Underground Injection Control Program,
1 6 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield
(gpm) 020 Method of test:1((,(hifrklho� 24c.>; &i action Wells: In addition to sending the form to
the address(es) bove, also'submit one copy of this form within 30 days of
/�
13b.Disinfection type: l (OnY.e- Amount! completion of w 11 construction to the county health department of the county
where construct ,
Farm f11.V.1