GW1--04716_Well Construction - GW1_20240812

WELL CONSTRUCTION RECORD (6W-1 i - .- -
1.Well Contractor Information:
'-- oSLt gere5S 11. ATE.R LONES
I F R(At If; DESCRIPTION
Well Contractor Name it. ft.
LI l V( lk -- ft. ft.
V is(!(ostractot t ertitIcation Numb,;,. 15,OI-I I R CASING(for multi-cased wells)OR LINER(if applicable) i
1 /U C`t ,(��( + ( .-klt(t�l 1() ()WITTER THICKNESS �[.a MATERIAL
�..(, IIMI Il�� ft. ft. in. i
ontpany Name
Is.INNER CASING OR TUBING(geothermal closed-loop)
.
2.Well Construction Permit#:
Kt t'I I11 ' DEAMETER THICKNESS 1 MATERIAL.
'in/an ur,r,YteC hlc,t ell c01tc,r,t:11011 permit,,,c. ,','( c rt. e(v ft. I Li in. t',•t'i p k�j
3.Well Use(check well use): ft. (� U ft. in. �G(J
Water Supply WelkI t?.SCREEN
1BO\I I TO DIAMETER SLOT SIZE THICKNESS )IAIT.RIAL
Agricultural Elti1m Icu t:) 1'uhlic ft. `r in. r��)( ti. 1 990 G' 1r N J A��
Geothermal(Ilcaling/Cooling Supply) esideinta;Water Stipplp. (sing let P-n. ft. 1 in. 7L•,
Ind ustrial/Conmmercial D'Rc.idettut:i \\suer tstippl I sharedi I t
19.GRIN
Irrigation ' I ttO't To i MATIRUI. E\IPLACE\IEN T ME1'HOD&AMOK N f
}Non-\eater Supply Well: 0 rt. 90 rt.. FN� ytl"cb7 0ow I (05ec
[ pvlottitorintu ORcroyci. II. n. /
Injection Well:
Aquifer Recharge
rt. ft.
DGrotindsatrr Rentedtatin❑
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity'Harrier FROM ! TO MATERIAL E\IPLACE\II:N 1 MF IFOU
Aquifer Test DStormwater Drainage a�5 i't• i rle�o ft. J ����'
Experimental Technology' �Suhsidenec Control rt. ( n. I
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if rite essary)
FROM I TO DESCRIPTION(color,hardness,soil/rock type,grain size.etc.)
Geothermal(Heating/Cooling Return) J Other(explain under 421 Remarks) n. I{ ft.
Date Well(s)Completed: W'a—a ,L Well ID# ft. I ft.
i
5a.Well Location: L- rt. ft I . _
1� � (L t i V.
IAA(ter. 14411ri %, F5rt. , CO ft. I L c(,`^e'S-k:(,,,,,es S..�,...�.w'iL. * ,. 1
tt. 7
acihty Utrner Name I actlit tl)• u I'Tr]Lc ft.
(bet Pals IZ, 0,4,1e50 lt,� 07 bC u. ft. j
AUG 1 2 2024
Ohsvical Address.City.and Zip Ii. ft. -. .„•„' _
iM:
21.
REMARKS ... '..
(omits f Parcel Identification No :PIN:
—
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •----
f I'eli field.one 1st long is sufficient) 22.Certification:
IS, (AO Li N %. SI 761 w
4 lip 6'-3-.6.1s(are)the well(s) ermanent or OTeniporar} lung uie.t \''lt(' ntractor ?:u
tons 1_ /virtu. I IteraM c Niel'than the t,elllsi was(were)una•,t,
7.Is this a repair to an existing well: 'OYes or 1<o tt;r_.-1 c:.It'02(' 0/00 nr/5.4\'CAC 0 C 0200 well C onstrttcrm,:s•. ,a...,i:. l.t•.tan,(.
i/thrc it'a repair.Jill out known well construction inlornunion at^ci explain the name-of iitr cop,• if this record has been provided to the well owner.
o peas nti/er-?l remarks section or on rite hock of tin s/a,gin.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You ma'. use the back of this page to provide additional well site details or well
construction,only1 GW-1 is needed Indicate TOTAL NI I BEIZ anvils
construction details. You may also attach additional pages if necessar .
drilled: SI•BMITTAL INSTRUCTIONS
�1r
9.Total well depth below land surface: (X-I G (ft-) 24a. For :All Wells: Submit this form ss ithin 30 days of completion of'sell
gist..tuultiplc reel!-list all depths ifdinerenr texantprc-:'a 200-,. _ 1 uu-)
unstruction to the following
10.Static water level below top of casing: 1 S I(t.l Division of Water Resources,Information Processing Unit,
Jr Hater level is above casing.use• - 1617 Mail Service('enter,Raleigh,NC 27699-1617
!1
II.Borehole diameter: 7 7/4 (in.) • 2-lb. For Infection Wells: In addition to sending the for)to the address in 24a
l ah.tt c. also submit one copy of this form within 30 days of completion of nett
12.Well construction method: I\D C`•''J .n;,tructton to the follon mg:
i i e auger.rotary.cable.direct push.etc
Di'ision of Water Resources,Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service('enter.Raleigh,NC 27699-1636
13a.Yield(gpm) 4:20 Method of test: t�cd‘1g10 24e. For Water SunDly& Injection Wells: In addition to sending the form to
the address(es) ahose. also submit one copy of this form within 30 days of
13h.Disinfection hype: H17'4 Amount: c9 Itx. completion of sell construction to the county health department of the county
a lucre constructed.
I'..rrm GVc-1 North Carolina Department at Fin.t ronntenrll t 3uahts -i)Iv Lion of Water Resources Revised_'-_ :'tt: