GW1--01012_Well Construction - GW1_20240208

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WELL CONSTRUCTION RECO -- .(GW-1) - '•. For Internal Use only: 1 I.,...' - • ... ' • • . . ' . ....:-.••1.Well Conts#,Infonana-0‘n:• .' • • •. . • I ( ' • • . ' .
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• .P 4-
. I . . • •. •14.WATER ZONES P. I : •
FROM TO DESCRIFUON
. Well Contractor NOme -
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.... . /0:0 IL,1 AD•:: ft- I-1-1 i . .
1 ,- A . . . ft. ft• .11 r'.', ' •
NC Well COotrostor GotiSeotion Number. IS.OUTER CASING((or muId-caued wells)OR LINER(if so Ucable) •
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FROM I TO . ' I DIAMETiot. I maims natal,
11 1.(AITYICIAAI.6-1 • .
• . ts. ft 1 .. in.
•COmpany NUM .
,I . 16.1NNER CASING OR TUBING(mother:oil eftded-10:44 . • . .2..Well Constriction Permit II: i.1) .41 0.•:- • FROM TO .1 mamma Ill
Ire 4. /0,er-s • - ,.
3.'Well Use(check well use): • . • ft. . . It. 1 1. ' in. .
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•Water Snipily Well: • • • • • 47.SCREEN I
FROM TO .ft. .DUMLITER SLOT SIZE THICKNESS' MATERIAL
• DAgricultural • * -• .* •OMunicipaYPubli ft.e - .. i in.
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' OGeothemsal(Heating/Cooling Supply) Ittisidential Water Supply(single)
ft • II 1.164; ' • 'I '. -.. .
Obidustrial/Commercial
• . Res. identialWater SuPPIY(ihacd). la.Gnour • g
OIrrigation °Wells>100,00- 0 GPD • • . FROM TO MA EMPLACEMENT METHOD&AMOUNT
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. Non-Water Supply Welk * • • ' . . . • ft' ft-. . - • 21i e.i/''• . ,1 4.-x.04_
.• 0Mo.nitoring . ORecovery • - ft* . -: , ft• jitiefilksilf ,C-47.4 d• ' •
• Injection Well: - •
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• • • DAquifer Recharge • ,- - -ft. • ft.OGroandwatake.mediation •• ' •
19.SAND/GRAVEL PACK(itipplistable) • • . .
0Aquifer Storage and Recovay OSalinityilarrier - • ' FROM TO . MATZR/AL IMMACEMENT METHOD
0Aquifer Test . . . --, - •OStormwater Drainage 3 • •' .: ft:
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DExperiniental Technology 0Subsidence Contra • ft. f•
• °Geothermal(Closed Loop) . ' °Tracer . '20.DRILLING LOG(attach additional sbeeb if necessary) -..- ' •
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PROM TO
TO, ' - ft. • =CR/PIM War,lousbiessoanhitt.k Opt,grain size:ete) .
CIGeotheimal(Heating/Cooling Return) 0 Other(explain tmder#21 ReMarics)
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. 4.Date Well(s)Completed: 2-6--24 Well ID# •. • • . - ft. ' ' •Ift. 1 ,. . . -• . . . .
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• Well Location: . '. , .. ., • -,.- • • ' rt. •: ft. t .: •. -
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7._a_1(--. ri?0 0 F.-C. " , ' ' •••• ' ' ' • . ft • ' • ft ii ,
F -** •
cr..e ._...!ve Er;
- ; , Facffity/Owner Name • . .. , „,' acility/D (if S applicable) . ., • ft. . ft. ...II, , a uwohor as. ,'
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C6 16 iiti 5 . Le) •-•r • 5 ,n 6A i--...' - . ...• . - -•":1e. .• - ft. . if''..; . ••- ' . .8 ,0,.8 .20244.•. Physical Addlia.Ci4";al4 Z.IF " : • . r.-. ,• .
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' 1-:r--:.:7=1.-"Zn 772•C.:..-.;.:.7,-;"..h.V4 . '• atl--AliA.'- , 2 • . . '• • • 21.REMARKS,/ • H -
VeTia•Os;
• County • Parcel IdentifiationNo.(MN)-* . • . • .. ii
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5b.Latitude and longitude in-degrees/minutes/seconds or decimal degrees:
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(ifwell Sold,one lit/long is sufficient)
22.Certification: . •I -.. * ' • • ..
. • 31 33', 3/, ' N. . Vt I sigi-/ i. .w
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6.Is(are)the ivell(s):4rmanent or CITemporary . Signanne.olCeitiS W Data
• • *shining thIsform,lhlrebyeentAlthat...ledge)war Co din aceardancentth
• 7.Is this a repair to an existing well: • °Yes or o*• . - - ,.. 154 NOW 02C:0100 oi7754NC1 0 2 C.0200 Wdl cennttletton Standar&and ihat a copy
If this Is a repter.fill ora known well corntrualan heonninfon and lain the swum of the . ofthi•reecerd her bealiiewid e d jo e yawner-
'molest:der#21 remark..section area the back of Attie= •
, - .• 23.Site diagram or additional ell details: •
8.For Geoprobe/DIPT or Closed-Loop Geothermal Wells haring the same • . You may use the back of this pagc to provide additional well construction info •
• construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells •(add.'Sec Ova'in Reniarks Box1 You may also attach additional pages ifnecesszny.-
drilled:
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• . 24.SUBMITTAL INSTRUCI1ONS ' -
9.Total well depth below land surface: • 'OA a ! • • (ft.) .-; ' ' II i-
it this OW-A within 30 ys of well completion per the following:
i Famelitrie Wall list all depths relifferent(exa7nple-3@200!and 2@100)
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, 10.Static water level below top of,casing: 2.0 . 24a. For MI Wells: Original min.to Division of Water Resources (DWR),
- !twofer levd it above cartng:tae"+ .• .• .
• (ft-) Infontation Processing Unit,16 MSC,Raleigh,NC 27699-1617 •
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11.Borehole diameter: 4 1 V• • .c.no '• ' 24b.For Infection Wells:Copy to DWR,lbscierground Injection Control(RIC) ' .•
Program;1636 MSC,Raleigh,gp 27699-1636- ,, • •
12.Welk eenstruction method: /RD I akti--•a.4,..:, I : -• - . . . . .
(Le.. eotaiy -- .- i •
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the '
auger, „cabbi,direa push,ete.) - ' • -..
county environmental health department of the county where installed•'
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• FOR WATER SUPPLY WELTS ONLY: , - - • •'• •
. m,1611 MSC,lial-igh, C?.7699-1611
24d.For Water Wells prodridlgr-over 100,000 GPD:Copy to DWR,C4E'CUA *
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Panut•progr.a : 0
13a•teliklith)' A 6 . - Method of tat . CL:iis • • • . •
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13b.Disinfection type: /4-V I.- .Amount:'' g 6".". . • ' 1 1 • •
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•Fosse GW-1 , • * , ' North Carolina Department ofEnvimomentsIQuaffiy-gobrielon ofWaterR=oung4 .
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