GW1-2022-00168_Well Construction - GW1_20221219

WELL CONSTRUCTION RECO GW-1
,..,_ �� For Internal Use Only:
1.W�Jel11,Con�tr(a�cJtor.Informatioa:
• `" �� �� 14.WATER TONES
Well Contraeoor Name mom TO D1SmlIFt20N
/00 R v ft
NC Wall Contndor CmtifioatioaN n' ft IS.OUTER CASING for multi-wed we14 OR LAYER th Bmhle
W1�Yv)w\ ��(/ PROM TO DL1MEr;R MclafEss MATERIAL
Company Name ft. R
Q/-•/') IC INNER CASING ORTIIBING thermal dwell-loo
2.Wall Conatroetian Permit A: q mom TO DIAMIrER TBImOfLSa mATEaI,aL
L4taQapplmb4 wel ewwovcDonpelm/tr(Le U1C Cormy,Stmt Fmimter,ata) .�. j ft L ft f7 m. tr>L
3.Well Use(check well use): R ft is
Water Supply WeB: Ef �+ Y1'1 �) 7.SCREEN
OAgriculturd O1r�ipaMblic PROM ft ill ._ DIAMETER SLOT vi TmC6?lESa MATERIAL
ft _ in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
'
❑IndustriaU m Comem dentid
ial OResi "Water Supply(shared) R ft in.
I6.GRODi
Ohti lion OWells>100,000 GPD PROM TO MA EMPIACEafAfr METHOD k AN[OUMr
Non-Wster Supply Wen: O ft FL / t
OMonitoring EIRecovery FL Ft. I
Injection We ll:
OAquifer Recharge ❑Gmrmdwatrr Remediation ft ft
OAquifer Storage and Recovery pggl Berner 19.SAND/GRAVELPACKda liable
mdy PROM TO MATERIAL EWLACEMHR'Mr1HOD
OAquifer Test OStormwater Drainage ft ft
OExperimental Technology ❑Subsidence Control R ft
OGeothermal(Closed Loop) OTracer 20.DRU.JMG LOG aroch addi'oeal sheen laeasta
OGeothermal(Heatia lin Return) ❑Other Lc2lain under#21 Remarks PROM To as9am2oN sole.aw. wahaele ern
ft R
4.Date Well(s)Completed: 1 Z-rI-2't Wen LDN R ft.
52.Well Location: R R
--L W• flyvk.- All- R R
Fa(mL'H/Ozyanetibm, FuiLHIH(dappiiuM Ft. R
J
— V t� \ Os/I Rd ...R ft
Physical Adder,City,and Zip ft/ ft .
21.REMARES
Co®h' Peed Identification No.(PIN)
5b-Latitude and longitude in degreesfminates/seconds or decimal degrees:
(ifwell field one htn"s 4 sufficient) 22.Certification:
3l, , IL , -� T N RI ' / ' . q-q . W .
6.Is(are)the well(a): nent or OTemponry l L�aL)A TWaune bfCwhfiedWen Contractor Date
Byrfgnfrrg thif f0rm,/hereby C016[Am the w ff(,)wm(ern)0otaatrrAedb aoxnlmtce with
7.Is this a repair to an existing welh OYes or ISA ACAC 02C:0100 or'ISE ACAC 02C.0200 iFe!l Cpunuctlon Statdads mMthat a espy VIh44 a rrpaerfl nmbean x Hcoaotx0onh�aramnan and run am whirr ofthe efohis recwdhm bemprom&dto tha w Hotmer.
'rrpafr order gll r mm*r radlon oroe the bw*gfbViforar.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Went having the same You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed Indicate TOTAL NUMBER of wens (Add'Sm Over'in Remarks Box).You may also atlarb additional pages if nectuaty.
drilled:
O 24.SUBMITTAL INSTRUCTIONS ,
9.Total well depth below land surface: '
Formalttple wrl4l4r ail drprM yNfferdi(erampls-3®700'ord2®100� (tt) Submit this GW-1 within 30 days of wen completion per the following:
10.Static water level blow top of casing: 24a. For All Wens: Original form to Division of Water Resources (DWR),
If.,.,lrvel is ab.mrtngyrr'+' (R•) Inform Uw PrOc iug Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. 6/� ,(•m•) 24b.For Iujection Wens: Copy to DVM Underground Injection Control(RUC)
12.Well construction method: Ol
L�t4 A,- 'Program,1636 MSC,Raleigh,NC 27699-1636
_/` —
fin augw,mrary,cable,d'nect push,era) 24e.For Water SuM&!jj22jR:jAqp Geothermal Return Wells:Copy to the
county(inwonmental health depadment 0 e county orb—mshnud
FOR WATER SUPPLY WELLS ONLY: '
24d.For Water Wells rodadn over 100 000 GPD:Copy�ro DWR,CCPCUA
13a.Yield(gpm) � C) 0 Method of tat: /{Vv Ptnmt t¢am•I I1 MS Ralegh;NC 276 -111
tt
i
136.Disinfection type: r 1� Amount:
Form GW-1
North Carolina Department ofFmhoomsnnl QmiiH-Division of Water Resources
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