GW1--02391_Well Construction - GW1_20240423

WELL CONSTRUCTION RE('OR1)(Gw-I) ror lnkinull i!v Tmly
1.We11 Contractor lnflnllcltim: k 3 7
Nick Young - {{{
14.WATER ZONES
\\'ell lOnRact+q NameFROM TO -nr. PIRY'1
4605-A ,S3-R I .$V ' ' 3 o
n. D.
-
NC Well Conaactor 'c tilicamsn Number
' IS.OUTER CASING(for multi cased weld OR LINER(if applitnbie.)
N.W. Poole Well and Pump Co. FROM TO� DIAMETER rTJIK KNE'St i MArEFLu-
Company Namc 4•1 rt l to\rt 1, In* t l 1r7 I G19.,J,
F /�� 16.INNER CASING OR TUBING(grolhermal closed.k.p)
2.Well Construction Permit#: l� ?�7 DO 1 d LiO mum TO DIAMETER F TJIK.K`4EQT 1 MATERIAL
List ill nppircable wt-II etnu»ucnon pernna(tee.6'IC,Csunry.State;r limner,ctc) ft ft. In
3.Well Use(check well use): n n. in
-
\Vatcr Supply Well: 17.SCREPM `-
FROM ro DIAMETER :4LUT SFLE IIIIEKNITXT 7 WATERIAI.
❑.1€ncultural ❑Municipal/public n. R In-
❑Genthamal(Heating:Cooling Supply) ilt$esidcntial Water Supply(single) R R In.
❑Industlial'Commercial ❑ResidentialWaterSupply(shared) -
16.GROUT
lmeation ❑Wells>100.000 GPD FROM TO MATER1It�i�. IfMPIArEMF:.T 11ETHOD&t.M01:74T
N'Non- aterSupplyWvf: C� ft 10 it 2-_i._[)`r
O\ltotitorin€ ❑Recovery R n.
Injection Well: _-,
ft. R I
❑Aquifer Recharge ❑Groundtwter Etc-mediation19.SAND/GRAVEL PACK(If applicable)
❑Aquifer Storage and Rmov'ery DSalinity Ranier FROM TO MATERIAL ESPL%CEMIZ*1 ME.TLIOD
0Aquifer Test ❑Stormwattx Drainage R R
❑Experimattal Technology ❑Subsidence Control R R
OGeothmnal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets IT necessary)
OGe�othamal(Heating/Cooling Baum) ❑Other(c�plain under#21 Remarks) FROM TO DESCRlPi10 Vi ier,nsrdnna aWrocktrpr Rim arc tin)
, �+ CI ft a' n. -v e,.�rn�
3.Date Well(s)Competed: �(�e7_t2 Li Well IIkI a n• 'a S"n- C/p..v s,-,,..(:.,•1 1,r)
5a.Well Lo©tion: IdSR a0 : C/a1� APR 2 .O24
�Ll8 ‘401wes Ittc ftJ// 1r
Facility:Owner Name Facility IDS(ifapplicable) It IL ._
5-38-f fiver-tick(1k tz.cl Spry Nrcc IlC rt. ft - :.. .3
Physical
Address.Cary,and Z:p rt. rt.
,{l,ei,s!,L 21.REMARS3
County Parcel Identification No.(PIN) Used steel hardened drive shoe
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell fold.one tatilong is sufficient)
s_ q 4-t,� N - 7k- IZ(o31 •22 Certification:
3
6.Is(are)the well(s): OPetmanent or ❑Temporary Signal c et ell Contra r
By signing this fore(I hereby ce ity that the well(:)war(were•)crrutructad:n a car:..,.ve n,.,
7.Is this a repair to an existing well: ❑Yes or tNo 154 NCIC 02C.0100 or 15.4 NCI 02C.0200 Well Cnasnucoan Stsmdnit Jed:^.0 a_,•
if tlos is a repair,fill out known well cmutrucoon information and repla N n M nature of the of this record has been provided to the will sweet
rcpar under u21,emarkr s rnon or on the back of this form
23.Site diagram or additional well details:
&For CcoprobelDPT or Closed•Loop Geothermal Wells having the same t"ou may use theback of this page to provide additional well Caxtst to e n 1;
construction,only 1 GW-1 is ruled. Indicate TOTAL NUMBER of wells (odd'SIX OveY in Rat ales Box).You may also mach addisea a1 pages r:neec,u
drilled: 24.SU1BM11TTAL INSTRUCTIONS
9.Total well depth below land surface: 2,O S' (ft.)
I•hr multiple wells Fat all dplhs ftf•n•N(example.3 00•and?WOO') Submit this GSY.l within 3t1 Juts of well completion per the following:
a o 24a. Fur All WART: Original form to lin is:on it U 1..T :s.I� u.rC:t :,01A1111
10.Static wafer level below top of casing: (It) Information Processing Unit,1617 MSC,Raleigh,NC_-tin)-lop'If water level is above casing,use'•.••
6n
11.Borehole diameter: (In.) 231s For Injection Wells:Copy to llNR,t'ndT ground lt1;el::w t �al OIL
veY?
Rotary Program,1636 SISC,Balogh,NC 2'0 0 to% 4
12.Will construction nwlh Fd: 2Jc For Water Supply and Open-Loop Caothenuul Return\Leif r,sort
/i a ,:gcr-Unary,cahk,.hncct Penh.do.) p �"'a'7
county envaunmental h,wltir d yourwat.if th:..w.1:s Aber:L;u'.Ielli
FOR WATER SUPPLY WELLS ONLY: 23d.For Water Well.pprluttk•lq•ourf I Wt) O I:Pik l'..,es to L)w .(CIPCLLI
13a.Yluld(gym) O 3hlhud of test:Blow Pcnud Pructatn lull IISC'.Rif,.'l:C-CCr`_',.01. .,,t
HTH
Jib.Disiuleetiou type: Aaulwn:
t
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