GW1--00928_Well Construction - GW1_20240209

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WELL CONSTItUGTION RECO •
.(GW 1), .For Internal Use Only. .1. •
1.Well Contractor•Information: ' --
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Well CoatractaE�hmo �� • •14.WATER ZONES ' 1,y ,• '
FROM TO DESCRIPTION
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Ott � rf,
•eellCoehaetorCe:dsatioaNember - J
IS OUTER CASING(for maTercased we16 OR INER o Gnble)
•
• PROM TO . ' I DIAMETER
Company1ame ft. i
MATERIAL
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�1 in.
2.Well Construction Permit if: ! 7•',�v! fi 16.1NNER CASING OR TUBING el ed-oop) • •
2.Well
pCons uct ion Permit PROM ToMATERIAL pamhr(l e.WC Cototry,'Slat Ymioncc•eie) t .ft SC.
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3.Well Use(check well use): • • �f/,� THICKNESS
TA)C�^- r�
Yt ft1 in.
Water Suplily Well: • 47.SCREEN I
• OAgricullutal trlicipaUPublic PROM I.TO DIAMETER SLOTSIZ6 THICtsrllrSS MATERIAL
• °Geothermal tt R _ ;®
(Iicatirtg/CoolingSuPply) 'dentist Water Supply(single)• .
OTmdustriaUCommeroial tt ft p 1 in•' '
Residential'Water Supply(shared) N
ga• ]Z♦.GROUT OTrri tion • °Wells>100,000 GPI/ ' • FROM TO tV A EMPLACfau TMETHOD&AMOUNT
• Non-Water Supply Welk �/J '
°Monitoring °Recovery• v G� /Y/:y s r� ` .
Injection Well: •
•
t p
OAqutfefRecherge . °GroundwaterRemediation rt. M
°AquiferStolage and Recovay • t7SalnlityBarrier •
19.SAND/GRAVEL PACK(if pplicable) • • •
°Aquifer Test fStmmwaterDrainage r PROM ft TO ft MATERIAL > lacfalExrMsrsoD
°Experimental Technology °Subsidence Co •
ntrol u ';
tt yt• u
• °Geothermal(Closed Loop) • • •['Trace •r tl • •
°Geothemml(Heatin(Heating/Cooling PROM
DRILLING LOG(athehad'ditionalsheebifaeassary)
g Return) °Other PttoM TO DESCRIPTION(color,hardness, r
(explain under#21 Remarks) _ ft ess,unfrock tree,cram ate,ere.)
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4.Date Well(s)Completed: I —3 C) 2 tt .Well ID# it •
Sa.Well Location �'
/
• Fac�iity/IN/et:Namo• . ry I' 't6 . -. . - . - ' . . . ft. ft; 11' I! •" A �/ L. .,,.
Fac�7ityID/(tfappliablo) - !t R 9 •
p an VI% 2, I -i 1 l3 A� r �'� FEB 0 a 2024
•
ft.
f1 A 2LREMARILS/ l~t`�t ipn;3rGfji4110�,t
G l (t1i13`.>Cn.
PueolldeotifiatiOnNO..(rR0 I .; •
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Lt/long is sufficient)
5 ) rr// c, 22.Certify n: _ �� C J L.
! �b / 5l�N gi I •, Cl 1 iG ' ••W •• I . . •
6.Is(are)the well(s): [ ermanent. or• °Tern o �j • I Z��- zi .
''`` P Y �.0 ?� SigmhQebfCemSettWeDContractor; Date
7.IsthisarepairtoaaptistingwelL• . °Yes or p Bj'signing thk/brm,!hereby eertllfAhorrhevell(r)vas(were)eonrtnruedL,oxotdarcewith-
1 tIsthi r __-_ __.. _ _114 NOW 02C:0100ar7.1.4mlc02C.0irier. CpnrnuedonStm d acopy
j ryalr OH brown ve/l gautrualon h+forsmtlon and the norm eft& of this ream i1har beenprw/ded/o elrell airier.
•Sepalr under M remarks secOn or on the bock ofth/:form. ,
23.Site diagram or additional well 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 Reaiarics Box You may also attach additional pages if necessary. `'
drilled: . •
t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: .
FormuGl levelLrll:rd!depths ', � (ft.) II •��, ,
ljdyj •
e:enr(example•3(a)I00 emd2(a(.100') Submit this GW 1 within 30 d pi ofwell completion per the following:
' 10.Static water level below fop of easing: �(J:r 24a.For All Wells; Original ` '
ljvoterlevef tr above earin&;use-+' • ft Ica to Division of Water Resources.(DWR),'
• ( )• Information Processing Unit,16 7MSC,Raleigh,NC 27699-1617 .
11.Borehole diameter. {in.) . 24b.For Injection Wells: tl DWR,Ur
Program,1636 MSC,Raleigh, 2769 - "Underground Injection Control(I - -.
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12.We*construction method: I'?b-- ._A� 9 1636
(Le auger,rotary;able,dheetpwb,ere) 24c.For.WaterSupply and Open)-Loop Geothermal Return Wells:Copytothe county environments►health department of the county where installed
• FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing:oyer 100,000 GPD:Copy to DWR,CCPCUA 13a.veld(gpm) Method of teat: ���Gm•• . Permit Program,1611 MSC,RaI`Igb,NC 27699-1611 • , r •
t
13b.Disinfection e: 11 v:/••
•
'Fenn GW4.
North Carolina Department ofFnriro mental Quality-Division of WeteiRe sees:• 1 Dom,..,,,,.