GW1--06741_Well Construction - GW1_20231023

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WELL CONSTRUCTION RE •
CO. (GW-1) For Internal Use Only: ., :' 1
1.Well ntractor•Inrormatio • ( ._ ... - , ! .
. ttiZe, e. ..e_4-Ile . . .
" Well Connector Name 1�.WATERZONES
FROM I TO DESCRRTION
3673. • /a) 4DU
' NC Well mb
Contractor CntifieationNaer ft. it f
/�/�/,� / /� • la.OUTER CASING((or mnlH�sed wens OR LINZR(crap Seable)
U'AAJ0 eilele. .. ,/. _ , .� FROM TO DIAMZTLR
�C/H.C�l I 'IBICKN1Ss MATERIAL
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, Company Name - g I .�
' 2.'Well Construction Permit#:* tO 9 �W 16.INNER CASING OR TUBRtG(Reotheri ra!eloped-laap)
Lis/aU epp/1m fr wrll eonrtrueNon elm/tr 4(JI FROM TO IAMErER.. TRIMNESS MATERIAL- P n C.Comrt) State.Keane",etc) • fj •ft• /O g ` Isl.- _a 11� r.. f
3.Well Use(cheek well use): ft. clod)/L
ftI 7 . Ia
'Water Supply Well: • - d7.SCREEN • • I
, • °Agricultural - 'OMunicipal/Public• PROM TO DIAMETER SLOT SIZE TRIMNESS MATERIAL
OGeothermtd(Heating/Cooling Supply) _ 1°
upp y) P residential Water Supply(single) ft: to • - •
Olndustrial/Commerciai OResidential'Water S' 1 sIn.
uPp.y(---0 IS,GROUT OIriigatiotl • • •°Wells>100,000 GPD . FROM TO MATERIAL, E111ZIACTMlt(rMErHOD&AMOUNT' ?
Non-Water Supply Well: • . -
G ft- ft: Area!,
-- • °Monitoring _ _ .. ['Recovery --- - - - -- �l)(P C� - - - -.1 -
Injection Well: -
ft ft. . ft' 9 ra14..6 T n'IAmpe�-
OAquiferRecharge . OGroundwrdterR,eMediation ..
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OAquiferStorage and Rtxovexy °SalinityBerrier 19.SAND/GRAVELPACK(ifapplicable)
FROM TO
°Aquifer Test . . • OSt�ozmwater MATERIAL EMPLACEMENT METHOD
Drainage t !G g i
°Experimental Technology °Subsidence Control • R -
i
• °Geothermal(Closed Loop) • , °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
°Geothermal(lieating/CoolingReitum •°°thee PROM TO DLSCRIPLION(nbr,�arda
(eicplairi render#21 Rematb)
ti ess.unfrock Inn,trail the.etet
'4.*Date Well.
Completed: /0=17e?3WeelliD# U9171/id . :z
5a;WellLocation: -.- . . : _. - ft• i<
Cons ' ft ;
. : '
' f ft. ,E..,;i 11...;,
.• . `•Faht(OmerName " - .Facility3D (fappliable) t
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/t ....ti , 1� Q/)2� a -� ' - .f- . - .O I ? v ?fl?aPhysial Address, o� � z 1C .` . •.•_H ;id,: C1ia) /.3D/3a�J 2LABIUM/ , ' '�
• .PaeelIdeifiatioallo.(PIN)m
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one laf/long is sufficient)
.36�l0 � a N D
• • 22.Certification:' •
.4004;. 641,4,1 . .
• 6.Is(are)the wells): rmanent or- °Temporary Signature bf ertifi' ell Contractor Date
7.75thisart air_toanexisting BysdnMdthlsforn,I hereby ee7Nfylhm the wel(s)wari{sere)eoitrovetedfaaccordwieewith.
• P well:- • °Yes-or'�f�i7o-. , . = - --15 4 NOW 02C:0100 or7SANCAC 02C.0200 Well Coat cifon Standards and tat a copy
I,A/s►sa repa/r fi/l autdao»n well ebnstruction tnformafon end certain the mums ofthe ofthis real been provided to the well owner.•
• 'repair under 021 remarlsseedon or art the backofit!:form. -
23.Site diagram or additional well detailsi
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8.For Geoprobe/DPT or Closea-Loop Geothermal Wells having the same '. You may use the back of this page to provide additional well construction info
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Rlmari s Box).You may also attach additional pages if necessary, . •
1.
drilled: ••
24.SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface:. • ' C,40 • ft
For mtdtlple wells list all depths iifd/fjerent(example-3(�100 and7(o)1000 ( ) Submit this GW_1 within 30 days of Well completion per the following:.
10.Static water level below top of asingi � ( ) 24a•,For All Wells: Original folio to Division of Water Resources (DWRt),•
lfvmer level is above ear►n&'tue"+- ` Information Processing MSC,Raleigh,NC 27699-1617
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'11.Borehole diameter: '•:` ' .(,�S' '•(m•) •- • 24b.For Infection Wells:.Copy topWB.Underground Injection Control(IUC)
��� � Program;1636 MSC,Raleigh,NC 27699-1636 .
12. construction method: tyt.L(/ .
air is Well coast cable,diteet Push.eta) �� 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the •
county environmental health department ofthe county where installed
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• FOR WATER SUPPLY WELLS ONLY:.
• 13a.Yield m • •
24d.ForWater Wells producing over 100,000 GPD:Copy to DWR,CCPCIJA
'' Method of test:• (,i v1JProgram,1611 MSC,Raleigh,NC 27699-1611 •
,1 • ►% • ,
13b.Disinfection type: / rV . Amount:. AI ' • { '
Form OW I North Carolina Department ofEnvimnmental Quality-Division of WaterResources
. ., , .. Revised 6 6 Zola