GW1--05475_Well Construction - GW1_20240912

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WELL CONSTRUCTION RECORD(CW-1) For Internal Use Only:
: .
I..Well Contra,:or1y rmation: ..
, ... ,
..-_,." 61, 4 '14:.11-ATERZONES.: ' . ',' 1 ? .•. -. _ - -, .-.. • . . -
FROM TO DESCRIEH1ON.
Well C tit ntor Manic
Neweit 'ontrar2 tail-motion Number '.15..0tITERCASING,(for tiralti-msed Wells).0ft LINEROf OP ili6ible):,, ''-,.
rtiost 1 TO . DIANIETER,' THICKNESS MATERIAL,
47 rt. I :40 rt. ,...„/ I:
"T61A4-01 0
(A'2w.AnaWiviiPeeall'.1c!'seINui ti:tI'prnzietConstruction,Well: Pe rinCi t 11/: :4415 (..°' .,_16.LNNER C-AkiNG ORTU111NG ideorberio tit elweit:loon)''':'ii, : -",,3",--"..-:---.,:,'",..,... '.-_,
FIRMA 10
ft. • DIAMETER THICKNESS I AtATERIAL
ft , in.
List all applicabk nell constrt.etion permits(ie,LIC,Cathay,Stett,lizeiance etc.)
ft. ft. in.
3.Well Use(check svell use):
_.Chire;• :eironnial(lleating/Cooling Supply) 1:321. ResidiceniPtialflik%th'altiecr Supply(single)
•Industrial/Commercial
•Oftesidential Water Supply(shared)
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_ No:4,7:1VnitIca,tricir:YPOY We :... ____,, _ E3cloundtvateritemediatipn
Injection Well:
1
Aquifer Recharge )
Aquifer Storage and RecoVei ' - - 'E3liPecTr37
D Salinity Barrier .t1117.0.S,C1 ift:E1N-t:0':: ''f',..."-''ni.,...:'..i'E.-r:-.E.itri..:1, . SLOT ST'./,' E. 'Ti.11NSg' . DWI,
/',e g.': 1,- 1 'ft,',
FROM TO ' NI•TERME Estriamt ENT strition.s.,ANIt)UNT
0, ft. . ta ft. ),),, ,•••
ft..
ft. ft.
rt.
. ' •
. 19:SANI)/GRAVtil,PACK(if uptiliculilii)-' - ,' ,-.-,".,.,•' .''' .- -:- .`,."..").."--•'-'•
PROM To 1 ALATE IAI— , E.111)1.ACEAIENTAIETH0D
Atinifer Test DSiormwatcr Drainage : ft. .i. :' ,
fr. , qtr-
0 i ..4.• -,'•. . 0...././.
R.sperintental Teehn gv OSubsidenee Control ft. n.
Geothermal(Clo- Loop) Tracer •20.-DRILLING,LOG(attach ridditionarsheetsif ticressuillf--r FROM TO DESCRIPTION Rotor.19 nlitcu,sor"3:'51:.`ttre.v,F-Ain,pv;F4.',)
Geothermal(livatingiCoolin."Return) :;, Other(explain under 421 Remarks) 1 • ii •—s A • -:-..-
f t. ... .,.?....5.70.4 /
2 ''‘
t). V
4.Date Well(s)Completed: I i *Well ID# ft. 6 re. /' :,
, maireder, Aiffidr: .
-ton
5„..,Well Location: . ft.
A'il.litylOoner Nana; Facility IDn kirapplicriblc) .0 • .2:___7/..y,j4
ft. 7, ,,,, _ , . 4•..0.20G
s,
ft. ft.
ft. ft.
. , , . , . ,, , - ,-..-., , .
s.
. . _ , „ .. ,,. .
Ph teal
Adjrcs C'IY'and"443Itt..):101,S-7 Cr:it 21.RLMARLS,. - -• -. 4-:- _ r .,.,, / . .. -
t.,
i J '
f'l 01)1 tlis .
COuray tPareet IderoitiPaion No.(PIN) /7(—,1 Ig—,-./) ••••21
5b.Latitude and longitude in degrees/minutesIseconds or decimal degrees:
(ifwq11 lid&one kallortg is.s-utlieicnt) 22.Ct.:rant:at
''''
' ' - /7 (..
C., 0.-1. '` .
*room.dr6ertitied Well Contractor Date
6:lstarelthe well(s){34titnent or DTemponiry
11),.illtning this form I Iteieke cell ffj.rim:the
well iv was-Orem)cinistructed in Txrattiattee
7.Is this a repair to an existing well: 0 Yes' or 121<" with 15.4 Nat('112C.0100 or 15.4 NC.,.k.`11.2C.020(5 Well ConsmictionStoulards and dot a
If rids Ivo repair.Jill out known.well construelleat thliiinuition anTlesplain the nature t?tire "TY'4-this reran!has been Prrhifkii to du'well swItep.
tvpair under...?1 remarks...seethes or an the hark of thiTTfomi
23.Site diagram or additional well details:
8.For Ceoprolic/DPT or Closed-Loop Geothermal Wells having the same You may use the brick of this page to provide additional well site details or sell
cAmsituction,only 1 01W-1 is needed. Indicate TOTAI.NUMI3F,R of wells construction details. You may also attach additional pages it necessary.
drilled; SUBMITTAL 1NSTRUCEIONS!
9.Total well depth below land surface: • ec, • BI-) 24a. For All Wells: Submit thi4 form within 30 days of completion of well
For multiple wells list all depths if elie,erent tesample-.5.?200'tint:1241001
construction JO the f011ossing:
ID.Static water level below top()reusing: 4 . (ft.) Division of Water Resources,Information Processing Unit,
if water loel is above easing itre'," 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole dianieter: ‘ (in.) ' 24It For Injection Wells: In addition to sending the fonn to the address in 24a
above,also submit one copy of this'form within 30 days of completion of well
12.Well construction method: itl•iff.4/6 construction to the following:
(le.atiger.rotary,cable.direct push.et0 .11
• Division of Water Resources,illinderground Injection Control Program,
ilOR WATER SUPPLY'IVELLS ONLY: 1636 Mail Service Tenter,Raleigh,NC 27699-1636 1
,T ce-
13a.Yield(gpm) / .., 'Method of test: ././..." 24e.For Water Sum&is': Infection! Wells: In addition to sending the lonti to
: * the address(es) above, also subntit one copy of this form within 30 days of
_131i Ilk' etion_tv_pes..",-t-s Amount:....j 6.'4. . completion of well construction to he comity health department of the county
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4%111.1C li..11.,11 arrest: I - - - - - -
Font;OW-I North Carolina Dimartmen)of Environmental Quality-Division of Water Rcoourcon I....wised 2-22-2016