GW1--00306_Well Construction - GW1_20240112

WELL CONSTRUCTION RECO (GW-1) For Internal Use On]y: . •
1.Well Contractor.Infor ation: y( fifir •
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�" • 14.WATER ZONIS I.
Well Contractor Name FROM TO -DE3CRIf720P1
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3. .. JAIL .13 30a n-. &2,0 k I
ft. its p
NC Well Contractor certification Number 3 15.OUTER CASING(for multi-cased wells)OR LINER(if■p licable)
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a r i .nc� ) FROM n I To IUME7ER TD2C7fNE55 nfATERtnL
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1
Company Name
1 5./ �/ 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: Y a FROM TO DUMErIR THlCloiEs3 MAMMAL.
List all applicable well construction permits(I.e.WC Como,.State.Variance.etc) 1' IL
/fi 3 (t, 5 y1
f 4 I( h vZ--
3.Well Use(check well use): ft. ft in.
Water supply Well: dI.SCREEN
❑A cultural FROM TO :DIAMETER SLOT SIZE T IC10YESS MATERIAL
❑Municipal/Public rt. ft .. I in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) .
tt ft p ia.
❑lndustrial/Commercial } Residential•Water Supply(shared) l#.GROUT X •
❑Irrigation L I
L • DWells>100,000 GPD ( FRO TO `MATERIAL IMPLACEMIRITMETHOD&AMOUNT
Non-Water Supply Well: p
❑Monitoring try. 1 It ZO 7 l]Recovery �� 't`j' f��
• Injection Well: 1--).
0
❑Aquifer Recharge� ? f);9i9. / n• f. 1
•
jr ASra:;Z';1 f ❑Groundwater Remediation
❑Aquifer StorageutdRecovatj�+ � ❑Salinity Barrier 19.SAND/GRAVEL PACK(ifhpplicable) • •
FROM TO IMRTZRIAL EM9LACEMUiT METHOD
❑Aquifer Test ❑StormwaterDrainage ' ft ft. 9
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❑Experimental Technology ❑Subsidence Control 1 R. a
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❑Geothermal(Closed Loop) OTracer R
20.DRILLING LOG(attacL additional sheets if accessary)
ft.❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) OM TO ft CRIFriQN(color,kardaers sril/nek type,grail.else,etc)
4.Date Well(s)Completed: I-4 - Well ID# t •n -
13 aD s 0
Sa.Well Location: -4' ft ft i
rn ut-- P t
. Sri ah A n-Ecak . it ft. I
Facility/Owner Name Facility ID0(if applicable) ft. ft j' p s
a a i - / � -� _ S o Lk A►� '�7 X� -'•� R. + I - ----:,...____-..._.........2)
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Physical Aa °`s Ci Zip
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� /1 • 21.REMARKS •
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County Parcel Identification No.(PIN)
56.Latitude and longitude in degrees/minotes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient)
3/ r _ 22.Certific lion: 40,441
l9 aa,� / �" N / ' �-7 • 8 • W r '-.
ermanent or ❑Temporary Signature ofCestiS' Well Contractor _ -s
Date
6.ls(2re)the well(s): J
By signing this form,I hereby tern f i hat the well(s)was(were)constructed In accordance with
7.Is this a repair to an existing well: ❑Yes or VNo ISANCAC 02C:0100 or'ISAJiCA 02C.0200 Well Construction Standards and that a copy
4`this Ira repair,fill out known well construction Information and explain the nature of the of this record hat been provides to a well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional ell details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this age to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box You may also attach additional pages if neerssary.
drilled:
4 24.SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: (ft.) �
For multiple wells list all depths Ifdierent(example-3@200'and l(�100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top o*casing: 6 D 24a. For All Wells: Original orm to Division of Water Resources
lfworar level ts above casing,,use~+�/ (ft) Information Processing Unit,16 7 MSC,Raleigh,NC 27699-1617 • � )'
11.Borehole diameter. o fin_) 24b.For Ia
---�iection was:-_ Cop to DWR,Underground IDjection Control(TUC)
12.Well construction method: 0+ ^ /T•'� Program,1636 MSC,Raleigh, 27699-1636
(i.e.auger,rotary,cable,deed push,etc.) 24c.For Water supply and O pen-Lao Geothermal Return Wells:Copy to the
county envrron nenta eprrtment o e county ere
FOR WATER SUPPLY WELLS ONLY: p
I Per24 For W W
ater ells prodtide;over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test aztn-- ermet Program,1611 MSC,Raleigh,NC 27�99-1611
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13b.Disinfection type: i t ! 14 Amount: f 2 ptii .
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Form OW-1 North Carolina Department of Environmental nhdii -n:..c.:_- -