GW1--00007_Well Construction - GW1_20231218

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WELL CONSTRUCTION RECO (GW-1 For Internal Use Only::, ')'• • ,
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• i.Wei ContractorInformation: • - • - • .• -
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•- • .• :' •14.WATER ZONES l'•. '
FROM TO DESCRIPTION
We ntrac Name
. 200 ft.: leo ft. 1, ? . ... .. ..
.3535 . • , ..
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ft. ft- 4i • . .
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NC Contractor Certification Number • '
15.OUTER CASING(for mold-cased wells)OR LINER(if ap noble)
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FROM I TO .. fe. I IHAMETER in. THICKNESS MATERIAL
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. 3‘ g', . 3.5-3 • ft.
. . Company Name1.•
' - 16.INNER CASING OR TUBING(geothermal rioted-loop)? . • _.- 2.Well Construction Permit/I:
, PROM.ft. TO D,IABIZTER5 7 71110(NESS . MATERIAL.
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List all applicable well construction permits(I.e.UIC ow*,She,Variance;etc) -I. I • 3 1 ft. i in.•• 7J i C pvt,...
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3.Well Use(check well use): . • ft. ft. in.
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Water Supply Well: • .17SCREEN
mom I.To • ft. I DIAMETER 1 SLOT SIZE 1 THICKNESS I MATER/AL
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• • ClAgricUltural 'Obitinicipal ./Pubjic ft. . - till' -
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. , CIGeothermal(Heating/Cooling Supply) ..f..lkesfdentird Water Supply(single) fr.. . • ft. 'il '"** . .
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OIndustriallCommercial , CResidentialVater Supply(shared) is..GRoln. . _ .. '•
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EMPLACEMENTMETHOD
' °Irrigation • OWells 5.100,000 GPD •:: , '•FROM TO MATERIAL
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Non-Water Supply Well: '
• 0, , -A)..t ft ntak•
AA;"-?( A q .
• °Monitoring '• ORecoverY - rt. ft
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. • Injection Well: • . • ft.ft. • / 1
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- ' : °Aquifer Recharge • - °Groundwater Remedintion
19.SAND/GRAVEL PACK(If applicable) •' '
°Aquifer Storage and Recovery • ' °Salinity Harriet • • •. • • FROM TO MATERIAL xraLACEMENTMLTHOD
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°Aquifer Test OStormwater Drainage ft. ft . . . .
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013xperimental Technology °Subsidence Control ., ft. ft ' k' ' ' • •
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- • . °Geothermal(Closed to'op) OTracer '20.DRILLING LOG(attach additional sheeb if necessary) .
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.13 Geotherinal(Heating/Cooling Return) °Other(explain under i/21 Remarks)- PROM TO DLSCRIPTION(color,bordoesosoWrock lipe,grain size, tc, .
.`• 4.Date Well®Completedr,1!-211'2-3 Well IN - ' fL. . .. ..it• ' 'L. i i-7.c• G a-1--I I n
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• Se.Well Location: - • • • .
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(j°6.
C-6 1 • 0:0),;,-1,. e-12. . , ..
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• •• .•-Fecal 4ft vine!Name. •• . . .
• ' Facility DO(if applicable) .. .. it - ft. I: :.,.4
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-T8 - • ai-rAs . C,"&ko RA
. ft. • ! 401 Li_A.......__ . . .
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. ,Physical Address,City;and Zip ' ' • ft. ft • 1, .e,-.t:( ,- .-...: ,.•,.c%;.,.-.,-.,
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CCP a(A.9 a' . . 1 . • • : • ,- 21.REMARKS i
- • County Parcel Identification No.(PIN) - 'I. :. • OEC 1 's ?fl;3 •
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• . . 5b.Latitude and longitude in degrees/minntes/seco --
nds or decimal degrees: . IpF-',7"r''.'..f7.P. ,-..'...-.i•,,:•-•-i '' P '
' . . (if well Said,one lat/long is sufficient)
22.Certin
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toO:'-ir .rI..,'t•r•-.38 Is ' (1 N i? 37 . . D 'Q.A.-.50•G' •.•-' '''F;4
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. .-6.1.(are).ffie_Weil(S):. ermS'sleet.-'-tir-- CiTemiortiry- _3 if 50- ... Signature f F,- Well Contract" Date.'.. . . - -
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' •:• • By:tiring this form,I hereby certihe that the well(s)was(were)Constructed in accordance with
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' ...7.Is this'a repair to an existing welt: ' OYes or, ..11No• : 154 NCAC 02C:0100 oe75ANCAC 02C.0200 Well Construction.Standards and that a copy
• .If this.is a repair,fill out AMOwn well conitructfon Information and explain the nature of the ; ,of this record has been pro?ided to the well owner. ,'
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. . •'repair under On remarks section or on the back of this fonn. - -
23.Site diagram or additional 7ell details: . " ' -- .
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' 8.For GeoPrnGeothermal se/DPT or Closed-Loop Wells having the eame You may use the back of this page to provide additional well construction info••• (add'See Over'in Rdniarks B ox).1 You may also attach additional pages if necessary.
• construction,"only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
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. 24.SUBMITTAL INSTRUCTIONS ' •
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9.Total well depth befell,land surface: 7 P° . - .. (ft.) • 4• I. •. .
• - - For Multiple wells lire all depths If drerent(example-3®200'and,2@l00) Submit this GW-1 within JO days'iof well completion per the following:
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,10.Static water level below top of casing: • • (ft) 24a. For All Wells: Original fo4n to Division of Water Resources (DWR),
-2-0 0
If water level Is above cosIng,:use .
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 •• .
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11.Borehole diameter: • (in.) • • • 24b.For Injection Wells:Copy to DWR,,Underground Injection Contid(IU C)
Program,1636 MSC,Raleigh,NC 27699-1636 - ,
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12.Welt construction method: •f-- 04-a.m.,,- at.,,,, , ...
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-24c.For Water Su I and L, en-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,eta.) . . /
• county environment eperlinent o the county ere in
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• FOR WATER SUPPLY WELLS ONLY: . •
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' .• ' - 1 1 • - • ' • . •• 24d.For Water Welb rochicin eier 100 000 GPD: , -•
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Permit Progran
130.Yield(gpm) a 0 . - • Method of test: .a.A•it .• • . ' Copy to D'WR,CCPdUA
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• 13b.Disinfectiontype: 1-k-II+ . Amount:. ' 1 2, 1-1,- : . : • •• . . • ! .. S
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