GW1--07205_Well Construction - GW1_20231108

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WELL CONSTRUCTION RECO (GW 1)
• I For Internal Use O
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1.W Contractor. orma'sr IL
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•Well x� •14.WATERZONES I t . =•
FROM TO I I DESCRIPTION
3S3 too it. (.,nod1l •
KFIVA]l Contractor C odas N ft n�
/ / (A l y>n �O R CASING(for.ululd-oEed welts)OR LINER(Hay
l.v�+v r t I DIAMETER 11ffiCIO'Q33 '1ZttgL
Company Name nlot_
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2. Cosfz action Permit f{: �F w` �'- 2 3(� 3 Zp 16.o�ER CASING OR (TUBING(geothermal doied-loon) .
2. ail Well Constr ire!!n Permit
I TO t 1 DIAMETER TEICKNES MATERIAL parasites...file~County.State:Variance,etc) + ' ft � ft t! ' s7/fly jo 3.Well Use(check well use): N o /i'[i t,�
Water Supply Well: • �7.SCREEN m '
• • DAgriculhrral D1Vjttntclpel/Pnb11C ?ROM TO DEAMErER SLOT SIZE THICKNESS MATER/AL
['Geothermalft ft ia.
(Heating/Cooling Supply) dential Water Supply(single) ft - ft p in.• •
❑Industrial/Commercial - liesidential-Water Supply(shared) E!
Dlrnigation it.GROUT }' i • •
❑Wells>100,000 GPD FROM TO I fIMATEELAL II14IACPMSM'METHOD&AMOUNT
Non-Water Supply Well: Q ft Z� g' D Are€r ,
• DMcaitoring DRe covexy G /V AA,-- ..e,/
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• Injection Well: • ft. ! O r�l +
°A4�Recharge ❑GroundwaterRemediation �. I / I
OAquifer Storage and Recovery ❑Salinity Barrier • 29.SAND/GRAVEL PACK Of am:linable) .
°Aquifer Test FROM TO IMATERreL >�IACEM1NrttiarSOD
°StolmwaterDtainage ft. ft
❑Experimental Technology °Subsidence Control .
❑Geothermal(Closed Loop) °Tracer • 20.DRILLING LOG(attael dditiooal sheet:if nccessast)
OGeothetnIal(Heating/Cooling Return) DOther(explain under#21Remarks) FROM ft. TO • fIDZS( TlON(cl.rt„odan:,n/reeknMory.sm, 1
4.Date Well(s)Completed: ii-Z Z3 Well ID# ' • ft 1; .
52.Well Location: II �`` _]] ft. Ip;
Cis eAr A )Yd..'• ft ft I' r-'ti 1. .4. '';'' - r .
• Facility/Owne Nam. Faclity ID#(sfapp}iable)•. ft. tt ; n` }
�bi -.Srn.� #-�1-.'� • 5' /� . . :R . •
la _ • - • NOV•' -8 2023y..
PhysicalMdrres,City sad2rp ✓. ( \ .� .'
Lk r� 21REMARL J '� if: a,^ ve7',7j-r' n.���S `t
County uu .y
Parcel IdentifiationNo.(PIN) • �!i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 11
(ifwell field,ono let/longis sufficient)
/ s C 22.C son: j •. -
V �.b , •N Y " J J n N i W ., :
•6.Is are the wells: •Is(are) () rmanent• or °Temporary Siiazaoegfem-et:&welContoetor Data
11 // Byeisning this fora,Ihoreby that t ewell(s)was(were)ouvasrasdinaeomdmacewith
7.Is this a repair to an existing welt °Yes or No 1SANC.IC 02C:0100 ar7SANCAC 02C.0200 Well C.onriracrion Stodmds and that a co ;
If this tiarapair,fill out lhtown well construction I formation ap(ain the ascot of the eats record hag bawl provided o the well Omar.•repair under f21 nwaa iaseWon or on the baekglethasfam.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells]raving the same You may use the back of this page to provide additional well construction info
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construction,only 1 GW 1 is needed Indicate TOTAL NUMBER ofwells (add'See Over'in R�iarirs BtI).You may also attach additional pages if necessary. ;
drilled:
/ Q 24.SUBMITTAL INSTRUCTIONS • .
9.Total well depth below land surface: (0 •
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Formultiplewells list all depth:yd8eraw( pk-3®.700'aid241100) (ft) Submit this GW-lwithin30,daysof well completion per the following:
10.Static water level below top of casing: (� D • ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwarerlevet is shave castn�ysse" Information Processing Unit,161I7 MSC,Raleigh,NC 27699-1617 •
11.Borehole diameter. Lo//7 {.) •
24b.For Injection Wells: py to D
Pro 1636 MS Rah ' I� Underground.Injection Control(I(TG ;
�j „y - /1 C► NC,27699-1636
12.Welt construction method:. 11 cT l ��1YV' , - '
(i.e.auger,rotssy,cable,direct method:.
cta,) 24c.For Water Supply and (pen-Loop Geothermal Retain Wells:t;opy to the
county environmental health department of the county where installed • - -•.�
• FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producint over 100 000 GPD:Copy to DWR,CCPCUA '�
132.Yield(gpm) 9- Method of test: CLA" Permit Program.1611 MSC,R�aleigh,NC 27699-1611 ti
f • t
13b:Disinfection type: -l-1l Amount: / [J vri .
Foam OW-1 Noah Carolina Department
ofEnvironmennd Quality-Division ofWaterRT7 Revised 6-6-2011
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