GW1--05765_Well Construction - GW1_20240926

WELL CONSTRUCTION RECORD(_COY-1) 1 For Internal Ulric Only-
'.Wep Contractor Information):
Nick Young
It WATER ZONYS
Well i ontractor Name — FROM TO a QRaCIW
4&05-A l`l G "�l' " / C-
R n.
VC Well Contractor Certification Number l-OIITLTR CASI1 G{far multi creed weld}OR UfEft()T appiksbkl
N.W. Poole Well and Pump Co. IltoM
t Tn ate,+ Ep Tre i39_IM .r
Company Naar t. , "- l )(.. n- f }tn. .\ 7 `^I c4\V e
' 16.INNER CASLNG OR TUBING(Aeotltermatebaat-taeRL
2 Well Construction Permit r: Ci/ FROM TO DIAMETER—. TmctcrFse J .tAt►Irr tt,
i.
Lia on oppb le,,,,,nee ,,,,,n cam 'a oette..penwue(1e.UIC.Cawley.Store.Pa hence..n, ) rt. n. In. I
3 Well Lice(check wrII use): rt. ft In.
Water Supply Well: IT.SCREEN
FROM TO DIAMETER Sr�TSIZE THV:-ICVF_S4 I .MATERIAL
GAgriculhtra{ ❑Municipnl'Rlblic rt. n. to
GGeothcreal(HeatingiCooiing Supply) idential Water Supply(single) R R. In.
I
ObtdustrialiCommercial ['Residential Water Supply(shared) ie.mom.
Glrriganen ❑Wells>100.000 GPD FROM TO MATERIAL EMPLACEMENT.METHOD&AM01
!Von-WaterSupplt Wcll: . IL L R x , ' .
P err\ O
Gidonitori.',c ORocovery n. R
Injection Well: I
—
OAquifer Recharge CGroundsva ter Retliation n. "nco
GAquifa Stange and Recovery OSafinih Barter 19.SAND/GRAVEL PACK(If applicablF1
FROM TO MATERIAL. ` E?tPLACE.MENT.tETaif
['Aquifer Test OStormaoter Drainage R. rt. Il
CExpcimeuai Technology ['Subsidence Control R H. I
GGcothermal(Closed Loop) ['Tracer 20.DRILLLNG LOG(attach additional sheets If necessary)
DGoothermal Heatusg,Kodmg 1larrn) .""I FROM TO DESCRIPTION(color,hardnr.;.Wreck trpa gain dm crc, -
( Other(c.gyp lain undo:*21 Remarks)
4.Date\i' O' d1I ,..." R ry R SC4 C)
eu(s)Coo'rptetlerk Well ID# R l lr n 44 �'
So Well Location: _ �. G " 1 � :ft.
({Li JC nF r
_� t7 i';01247"."'Th.
Faeilr Nasa Facility Ea(ifapplicable) R ft. 5EP 2 a
LiLl&9 nC sss-1 L ,L) Lxs n (_ R R
Physical Address,City,and Zip rt. n_ (��G1.Y.sad; ,; ?s-r,.
fir,\\a,el, 21.REMARKS _
Cc...:y Parcel Identification Na (PIN) Used steel hardened drive shoe
Sb.Latitude and longitude in dcgrccs/minutcs/secorids or decimal degrees: _ i
(if wcli o._a:'leng e s c;cnt) 22.Certification:
ccCL 9 I N � clC C2tt w cy 459_____
S ((G.Is'art)the weB(s): CFernnancnt or ❑Temporary Signet ear all contra r [Tenn
By signing Ills farm I hareby ce h then the wells)eta(Para)stwairaeaa/le ttetaordan:e wti.
7.Is this a repair to an existing well: OYcs or it No 151 NCAC 02C.0100 or 151 NCAC 02C.0200 Wd/Caamscaboatmaiorit and that a,;,;,
{Taw::a repair,111:cat known well construction urfornration and explain the native of the of this record has been provided to the moll owner.
repair under a211emar �;(ct,oncrenthebackofthisferm.
23.Site diagram or additional well details:
6.For GeoprobclfPT or Closed-Loup Geothermal Wells having the same You may use the back of this page to provide additional cell ec uln Coon Mtn
construction,only 1 OW-I is nc cdod. Indicate TOTAL NUMBER of mils (add See Over'in Remarks Box).You may also attach aidititaal pages if recessa;'.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth lydow land surface: 1 ('i (ft.)
Submit rids GW-1 within 30 day. o a PO.e.altplc writs list all depthr if different(example,-3(6200'and 2L100') f well completion per the following:
( , ( 24a. For All Wells: Otiginal form to Division of Water Resources (D\L;,s.,,
ft.)
Ili.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699.1617
if warm levc/a ac ci.c co.ung use". b
II.Borehole diameter: Err On.) 24b. For Inlet-Ilan Wells: Copy to DWR,Undsgr and Lnjection Control(It's..:)
Rotary Proy>ratn,1636 MSC,Raleigh,NC 27699-1636
12.Well crnutru nr a method• — 24c.For Water rat Supplypr I Copy
ir e sum ratio.rsole.duvet push,etc) and n-Loop r U Geothermal Return Wells: to Cie
county envirotunental health department of tho county wham inttali r
FOR 1F A'l ER SUPPLY WELLS ONLY: 24d.For Water Welly pmducln over too Pan GPO:Copy to DwR,CCPCL.;A
i Blow Penn Program,1611 MSC',Raletgli.NC 276911611
13a.Yield(gpm) I .e Mclhad of lest:
13b.Ulsltdettion HTH
H
type: Aflwunt'
l inn r;'N.I I lot h casulura Dap.riment of Cnvuunraental Quality-Division of Water Resoutcaa Rcv.scd 6.6.2::1 S