GW1--06628_Well Construction - GW1_20241108

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WELL CONSTRUCTION RECORD For Interact usearriY:
This form can be used for single or multiple wells .
1. s:i.-roc:.a Saf•-•_mat:_::r .
w Aef/1 ie/f) 14.FROM ER EaNESI ;Cl! t [ FROM TO I Dt~^RiPTdON -
Well Contractor Name ft. I ft.
. 11_,1 Zs- k ....:- ft. 1 ft.
v-rmne.eta nm}rr+i_r_.••••ia:.•., a•.,a'oei iaiiii=(i oxnun:4MAl
l�.v NT e:»•-L!!!l.FY",!•-..uuw.wu,•uuwv - .______________ ___ .. ..._.__ ._. _.
, d/iel i .
Corapaay Name ()✓ M 6e r t-f c 16.IlvNER CASING OLi TUIlING(geothermal closed-loon: ' . -
� �Q FROM I TO ! 1 DIAMETER` i THICKNESS I MATERiAL
2.*en C:ansiructton remit#: ) 0 1,2, 2 LI R 7, ' r9 . ! 2 Q
List.allapplicable well constivettonpermits(te•Count};Stara Variance,eta /• /) ^� `�/' L° { py
3.Well Use(ellecklsali use): /�/ [ 17.SCItEEFl
.
Water Supply Well: 1 PROM I TO MatuerER SLOT Tru limas i 1naiCluia,
u:ivi+uicuua.,(:ra�a.u,y ,,..,:iy.:..rt"y) -:__ .._ _- . . --a,_= E E E — ? �' _.
°hiituslrial/Cornnlereial °Residential Water Supply(shared) -ii.GROUT I'` • .
FR031 I TO MATERIAL i &MPLAC> METHOD&AMOIDI
O Irrifiaflon „L f/n p
. Nett•Water Supply wen: >ti f4 /30f�� `_..._
- OMonitoring - - °Recovery - - - I
ft it I -- - -, . -
Injection Well: �. ft. ft
OAquifer Recharge C7Cnoundwater Kemediation +�-a �Ol :: n.. �.. ,, .. ._
I I FROM W TO 1 n1ATSBIAI, j EMPLACEMENT METHOD
OAcuife ut�aic and Recover: aseriaiityBerriar f. 1
°Experimental Technology °Subsidence Control i i i
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) °Tracer FROM I TO r { DESCRIPTION(color,bn ess,solukoektype.Vansize,etc.)
j•DGeuikallai5iicnuusiwvi;iigi::,`Y:,.j - :(.,.:,.::;:r:,., 11''_=;fie) • ei 3'�i R' . il g.,c, ®//
4.hate Well(s)Completed: J 1'1 I Z�.
4 OR' 4)ft, y - -
5•Well Location: I c��9j it �,v tt. �v • �/ `}.. eE,`L I _ . 1
' Wain dr V.t. lie t Li a/1)-56a f 3 6 C!"•:. ! ' NOV-0 8 2024 -..
- E:`31E4I=»'F2iwril0 E Ti.. -- .
1.,) ?N k7 ci sl-,,,f, • ..,:170 1 0 7.,,,4
ft. 1 ,ti
Physical Address.City,and Zip Q
item,c4150
&Car) �J ti c t
County Parcel Identification No.(PIN)
5b•Latitude and Longitude in degreeslminuteslseconds or decimal degrees: 22 C: -: cation:
(Ifwan labld,ono Iasllorig is ounioloac)
c +
/.
6. s(are)the well(s): Permanent or MTempora
By signing this orn7,I hereby car*that the well(s)was(ware)constructed in accords
with ISA NCAC 02C.0100 or 1SANCAC 02C-0200 Weil Construction Standards and th
- 7.•15 lisle a z>iaiw to an case,-.g -:Yet _t ._ - :_, n^^!this recent/au has beeaprovtded to the well owner:
Ifthls is a repair,jilt ont lowlier well construction Information and explain the nature of the •.
repair under#2!remarks section or on the back of this form. 7,3.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or N
' 8:;Number of wells constructed: [ nev+ei,Mhm,details; You may also attach additional pages if necessary.
For multiple injection or non-water suppIywells O7VLYWit;the same construction,you can
ql ! 24.Submittal Instructions:
9.'1 oiai well tiepin vniviv iuuu au.ww: 6 7t7 30 Y 7 - =. . — -. =a S ti"_-_ ,_: _ :.__=?' >'_e rev,_ __ __"}}.}�•.••}...a .
.,. a -- :-__.� _- :. .` ._.._,. ..! ..e }
For multiple wells list all depths(jd(feren;(example-3©200'and 2((g100) construction tote following:
19}Atadc water level below too of casing: 3Q ( ) Division -
of Water Quality;information Processing Unit,
feater level Is above caring,um"+» I„I7'Malt c ••ei a Center.Raleinh.NC 27499_1617
11.Borehole diameter: irk (in.) Z41s.For Iniection Wells: In addition to sending the form to the address in
r above,also submit a;copy of this form within 30 days of completion of
12,Well construction method: — »tee». a,e 1 In
(ie,auger,rotary cable,direct push,etc.) r.,LLe............ .y_iv ..
nivisi e(Water Qlxalltyr Underground Injection Control Program,
i`-;_r- rip_p 2 -r` --_ ...... -.____. -•_-_
13a.Yield(gam) 3 (i'l Method of test: lac.For Water Subnly 1St Geothermal Neils: In addition w sending the inn
the address(es) above,also submit one copy,of this form within 30 days
'u. ,:si:,. .:-c 4�9c'r\. _ _... d completion of well construction to the county health department of the col
sr
(b
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- ._...,,.... 1 Wi1C1C W LLw.,.:LLJYO .1
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Farm OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised.