GW1--00006_Well Construction - GW1_20231218

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WELL.CONSTRUCTION RECO • :(GW-1) I ForInternal Use Onlyi
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1.Well Contractor.Informatioir'. • • (
well Cocie
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- - lel. Agoiret f 414 1141,4111-.. ? • ' •14.WATzRZorixs• II 11.1 ' • .
lge ..' . • ,FROM TO El DESCRIPTION • .
• • 41)5'IL. •q-aD ft- 1111 11 • - . • .• - - :' . ,53.s. • •
• ft. ft- 1111 .1, • __r
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.NC Well Ceotrecter CeatiSeation Number• • • 15.OUTER CASING(for niidei-eaThied well)OR LINER(Rap &able). •
CU;e1,. A. I I,- ...e,.... • .
• FROM• TO • : Emma=I I•:rmatmess 1 mamma.
COmpanyThune • • . IL _.• at H I I n' I •
16.'INNER CASING CRIBBING keethermal elaied.lotip) . • •
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' 2.Well Construction Permit II:. 35 ii•-(0 co •
. • FROM TO . • isslaPartert THICKNESS , MIOLERIAL.
L,10 all applicable well conwrucifon peradis(1.e.WC.Can%n Stale.Variance.eic) -I"I I.ft' I'65 ft- Hi Th,rc, pia--.
3.Well Use(check well use): • ' . . • ft• II .1 IL , . •• •
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Water Supply Welk. • • • • • 47.SCREEN( II I I • , .
• •PROM TO . DIAMETER SLOTS= isuCaNass• aLtranIAL ••' • ••
• OAgrieultural •OMtmicipal/Public ' • ft.
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, 4 • St• *A II 'i it l• • I . . I . .
0 Geothermal(Heating/Cooling Supply) :13itesidential Water Supply(singlei it ft* III I in. •
• Olndustrial/Commercial . OResidential•Water Supply Oared) I a.GROUT
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Olrrigation •oWellg>100,000 GAD .. , FROM TO MAUMAL . EMPLACEMENT MITHOD&AMOUM'
Non-Water Supply Well: • • .
- 0 ft• Al ft- iiilvea.i. • miyi.„
OMonitoring •• , ' ORecovery •
'ft. -- ' r;•-11-e,:, • - ,J .-
• Injection Well: : ... . . . .,
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• ft. II Puivii •
. • - OA.quiferRechStge OGroundwaterRemediation ' ft'•
19.SAND/GRAVEL PACE(if float:able) . •
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0Aquifer Storage.and Recovery •OSalinity Barrier '• PROM 'TO ' MATERIAL . rieuconiza?damn
0Aquifer Test OStormwater Drainage 3. . • • ft' • . ft• II Il . ' . •
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0Exprimental Technology OSubsidence Controln , ,. R. ft.• II 1/ -I; :-- • . ' . •
• . OGeotheimal(Closed Loop) OTracer 20.DRILLING LOG(attach Additional sheeb irnecessery) •
FROM ft. TO • \DESau.rpoN(clor.Minh a;soilkock ime.min sioe.etc)
0 Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks)
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4.Date Wags)Completed: 1 2.-.5-23 well Th •ii ,• •
. it. ...ft' II } •7717.) a et '• Cornt:s ., • ' :
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52.Well ioesfion: .
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To ci ot ('st ,r,:1),,,. :_-PA. .,.- .
• Facnity/OwnerName . . . -• Facility/DI(ifapplicable) " . "; ' ft• .11 II*' .• A.. . sqqfpn . • .
'._C /61-c i-rai'ls ' . . . A--- /Ld . -it: ik' 11 'le•' • ' P',•$:::1.- . -:E•i\i,,-::71 ...
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. . Physical ddress,City,=drip.
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, . 21.REMARICSI 11 I . I It. r i A 76,/1 . . •
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County t
Parcel Identification No.(PM) • - " . • . .
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IntoM1:••••-•::..,-. •,;.:.-•..,-::::!-.-...:::j ‘..i 1:i.•
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56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
• (fwell Sold,one htfieng is sufficient) ' 22.Certification: * II 1;• - • .
. 10i i gi i b" N. ' 6 ii• 3g. 1'• w
mg: ji,ji14- - . .11"':.'.. -j"- '. •
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6.Is(are)the well(s): OPermanent or OTemporary 3 2 /6 . , signabni . • eweRoJntgalfor I • - Data
11.Y.signing&Venn,IhiiIrby -. hat ihe well(i)war(wera.)Icessowessd In accordance With
7.Is this a repair to an existing welt Olfes* or .1kNo• • •ISA Nate 02C:010.9 oriI2VC4ç 02C.0200 FitlIcsnovetrai&min&and that a copy
- 1rthls tra repel:Will out brown wet 1 anuttualon heennatlen and aplala the sabre of the ef Ike ream 1 has bee ek
n PraFie I 11 even arm . . . , . . •
'refiair under 021 tzwarb sectIon op on the bOut of this/ann.. ' I
23.Site diagram or additional rX deter ' • •
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same• ' . You may use the back of&ill' age to provide additional well construction info
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• construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells - (add'See°Yce in Ralialks Box You may also attach athlittPaal.Pages iftlece=219-
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drilled: '
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. 24.sSUBMITTALDISTRUCITONS ,
9.Toill well depth below land surf:Ice: • 9-q.6 . • . • (ft.) ' L , . ••
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Submit this GW-1 within 30 4 ys of well completion per the following: , .
; ' Fr mulls wells An all deptla Y.different(cawirpk-3@200'and 2(0100) , .
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24a. For All Wells: Original 1m to Division of Water&sources
. 10.Static water level below trip ofcasingi • '&b . ,
. tft-) lafoimation Processing Unit,16 7 MSC,Raleigh,NC 27699-1617 •. . . . .'
rwaterkvent above eguiiig:use-1+4 • .
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• 11.Borehole diameter L.,_teli( „Cm.) - , • - . - 24b.For Infection Wells:, . to L,10,Underground Injection Control(IUC)•
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12.Weli construction method: ..1.-1.1---
• 13i " - ' ..l , • • ' Program,1636 MSC,Raleigh, C 27699;163.6 . • . • - . •
24c.For Water szEst and Open-Loop Geothenbal Return Wellr Copy to the •
(i.e.auger,=tau,cable,direct push,etc.) ,
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county environm ealth deportment of the county where installed
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• FOR WATER SlAPPLYWELLS ONLY
m ' • . - •-- . .24d.For Water Wells proddilieitT over 100,000 GPD:Copy to DW11,CCPCUA
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•. /-p. , _•••• ermigram,1611 MSC,Ral igh,NC 27699-1611
13a.Yield(gpm) i O • Method of teat a..w. • - P t Pro I • ti
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• 13b.Disinfection type:_ a
- Amount '. ' 41•-•"' '
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Feria GW- th1 •
Cazuttu;D•cPartmcat ofEuvkauncnt0 Quality-Divison OfitraterRelos. sp-c........•..........
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