GW1--03354_Well Construction - GW1_20230516

W11L CONSTRUCTIONRECO GOV I
!-� For Internal use Only.
' 1.Well Co,ntor•Iaformation:
14.WATER ZONES : +
Well Con4aetorN C FROM TO DESt3031IOPr .
�-� ` 7 —A ft. ft
NC Well Contractor C 12ificat, ft ft
15.OUTERCASING farmalli-cased Wells OR LINER If2P liable
• FROM TO DIAMLrER TBICKN SS MATERIAL
CompanyNamc ft is
3 16 l closed-lo
Ir 6..INNER CASIIVG ORTUBING eot brimao 2.Well Construction Permit#: � �
rl all appUcabk weUconrooaion pernyu(Le WC; D Cu+mry,Srdr.Vanm c4 era) & fy' . ri•
3.WellUse(checkwell use):
Water Snpl?ly Well: 7.SCREEN
❑Agricultural ❑Mtmicipel/Public: FROM TO DIAIF1FTiR SLOTstZE Tl�CRr�SS MATERIAL
ft ft �-
❑Geothermal(Seating/Cooling Supply) ential Water Supply(single) -
❑Industtial/Commemial
ential Water Supply(shared) is.GROUT
❑on do ❑Wells>300000GPD FROM To MATrRw, �uC�rrMerBOD&AMOvrrr
Non-Water Supply We1L• � _ ft
❑Monitoring ❑Recovery
Injection well: ft
❑AquiferRecharge ❑GmundwaterRemediatiou R f
❑Aquifer Storage and Recovery ❑Sa h;RyBanier 19.SAND/GRAVELPACIC rf a liable
;20.
M MATU AL EMPLACFI�ffNPMEMOD
OAquiferTest ❑StonnwaterDninage ' ft ft❑Experimental Technology ❑Subsidence Controlft❑Geothe�al(Closedloop) OTracerRILLINGLOG attaehadditionalsheetsifneeess
❑Geothermal(lieating/Cooling Return) ❑Other lain under#21 Rematirs) M TO DESQt1Yri0N color,bards soa/roek e, ;�uc
ft' ft
4.Date.Well(s)Completed: -q-23 . Wen ID# ft ti
5 ell Location: it g
r1 l'j 8
• Fa /OtvnerName FaerlitylD#(tfappliable) ft g
MAY I
PhysrealAddces;Ctty,andTap ft ft 1tl ,r,4, Ji1 { A fi t
21.RVIAMC91 n�
COS ParcalldenEffadoANo.(PIN)
5b.Latitude and Iongitude is degreedminutes/seconds or decimal degrees:
(ifwell field,one lat/long is sut$eient)
•6.Is(are)the wells) `-' -2,J
. manent or ❑Temporary f ) /�I Sigoahueof eIIConhaetor D�
X By JfPlna&ujoim,Jherebyce*rhat rheweU s war
7.D this a repair to 1m erdsting well: ❑Yes or p ISAXCdC 02C.OJ00 or7.0 NCdC 02C.0200 Wilt (we")
,CO uda a� a'4coa
Ijlhu irarepa r fiUominown weUconso wlw hrjonflar/on and col do the naMm o the ojrhis rewrdhar been Cot+*r+i+mon Stmu�di and}hat a copy
repair render J121 remar[s seeo'on Oran the bac,Eojthuforas j prav/ded to!hews!!awns.
23.Site diagram or additional Well details:
S.For Geoprobe/DPT or Closea--Loop Geothermal Wells}raving the same You may.use the back of this page to provide additional well conshuc o
drill doa i nf
construction,only 1 GW l is needed. Indicate TOTAL NUMBER of wells (add'See Over'inRdnimi,Box.Youmay also attach additional panes ifnecess ed
2,6 24. M1TTAL1NMUCTIONS
9.Tohlwell'depth below land surface:_ (ft) � '
FormuGP&we&Arstarl depdAr1fdl,�rrr�t(�mttPlo-g(o�00'ona2(a)100� Submitthis GW-1 within 30 days'of well completion per the following:
10.Static water Ievel below top of casing. (�) 24a.•For All Wells: Original form to Division of Water Resources (DWR)
Ijwaterlwelrr above earin&)se+" InformationProcessingUnk 1617MSC,Raleigh,NC27699-1617 '
11-Borehole diameter. / 0. 24b.For Infection Wells:Co D
��) Pro PY WR.Underground Injection Control(IUC)
12.Welt construction method: H• ._ 5 .1636 MSC►Raleigh,NC 27699-1636
C' a"8a=°tu]%cable,daedpusb,etc) ' 24�Foer..Wrraoter SSugeh and Onen--Loon Geothermal Return Wells Copyto the .
tY mAalhealth depalhaent ofthe county where installed.. FOR WATER SUPPLY WELLS ONLY:
•24d,For Water Wells Dradnciae over 100 000 GPD Copy to.DWR,CCPCUA
13a.Yield(gpm) Method of test: Pet»nrtog<em,1611 MSC,Italergh,NC 27699-1611
13b.Disinfection type: Amount: r r
Form GW-1
North C!unlro.Il....d.....- - -
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