GW1--00216_Well Construction - GW1_20231229

LL CONSTRUCTION RECORD Gw z •
i.Well Cantractor Information: For I�ernal Lst;only:
Tell Contractor Name ✓ Qb�F.?ZZOIV�y
/+1J I TO DESCRIPTION
V a/` I I f 1 ft ( r';Gil NC Well Contractor Certification Nuenbar
t v !� I 15.OU ER(y*ASINtiStormnt& ced'wetts ORZ
COIIlpanyName / dj j
INEI I i.,, ' rt. (7,/�; in.
2.Well Construction Permit#: _�(J �(-, .f� I MANNER CASING OR1'UBING en thermal e (
List nil applicable ttie(t construction permits(i.e.UIL Co O14I tTO _ {' closed-loo.)
State,Variance,etc.) r DIAh1ETER THICKNESS !1LiTERr4T
ft. in.
3.well Use(cllesitwett use): -- �� _
Water Supply Well: I "' ft in
17.SCREEN —
Agricultural mom TO DIAMETER SLOT SIZE
Ceotllermal(Heating/Cooling Supply) idcotial Water Supply terpaU?ublic ft. Tsrcrcrasss n ATen
g ' Rtsft. In
'IndpstriauComtncrcial (single) ft.Q1Residential Water Supply(shared) it� in.
18.GR011T
Non-Water Supply Well: FROM
'-� EMPLACEMENT METROD&AM
lVioaitoElpg t, TO
Recovery r ft ` '..
l Injection Well l! it
tfAt]uifer Recharge ft
Groundwater Rernediation
Aquifer Storage acid Recovery Salinity Barrier 19 't GRAVEL P.4LK
Ufa Iicable
Aquifer Test FRS TO MATERIAL
_ Q1Stonnwater Drainage
E6fPLACEMENT hlr•THor
Experimental Technology I I ft
�lSubsidenceControl ! —
t Geothermal(Closed Loop) tTraeer f E
Gt oFhetmal(Heating/Cooling Return) — 20.DIr:FI'LfNGLpG(cf-Tack uddi6onai sheets if necessary
Other(explain under/r2l Remarks} q FROM TO — DESCRIPTION Ica hardy tss,soi,., hardness-soil/rod; 4amiaszc•
�1Mil :it.lls)Completed: U ,3 WeII m �) ._
1.Date We
< <— ft. 2yV 1 st�La.Weil Location: ft r� L�
Q 6 1"r.
/ f U/1 ✓alS ft. if.
Facility/OwncrName _
?icilityID;i(if applicable) ft ft.
'hAiien
ieejAddress,City,and Zip
�oun� y7 0�''��7��w 1 =I.RP;IylgR1� . . _
Parcelldentin"catioallo.(PIN)
ab.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell Geld,got tat/long is suMcient)
C,3 22.Certification-
6.',scare)the wefl(s) rmanent or - 1lJ-/2,73
QlTempOrary / Sight of Certified.Neff 121'1 ttas ctnr Date
7.IS this a repair to an existing well: .yes or / By signing this form,I heieby certify that the well(s)was(were)constntcted in arc
I No wth 15.4 NCAC 02C.0100 or I SA NCAC 02C.0200 Well Constriction Standards DI.if this is a repair,fitl out known well construction information and explain the nature ofthe copy,of this record has been provided to the Melt owner_repair under::21 remarks section or on the back ofths form
23.Site diagram or additional well details:
3.For Geoprobe(DpT or Closed-Loop Geothermal Wells having the same You may use the back o:this page to provide additional well site details
construction,only I OW-1 is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9_Total well depth below land surface: '- '
For multiple we1Lr lists t depths tfdpercmrt(example-3@200'and 2(a�I00� - ( ) 24a. For All Wills: Submit this form within 30 days of completion
u construction to the following:
10.Statii:water level below top of easing: I�_
11 water.Std elev is above casing,use'_^ (f) Division of Water Resources,Information Processing Unit:
I617 Mail Service Center,Raleigh,
11.Borehole diameter: t.- �-. gh,NC 27699-1617
f��� 24b-For
/�,:i. Infection Wells- In addition to sending the form to the address
12.Well conch action method:. ]1 r rl/ above,also submit one copy of this form within 30 days of completion
(Le.auger,rotary,cable,direct push,etc.) construction to the foliowi og:
Division of Water Resources,Underground Injection Control Progr
FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gnat) �l •
t I ( ,}_ 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: L—y7-: 24c.For Water Supply 6'c Infect: In addition to sending the:
13b.Disinfection type: ' t v' the address(es) ahoy, also submit one
Amount: completion of well c copy hef this dorm within 30 c
onstntction to the county health.department
-where construcdepartment of the