GW1--01802_Well Construction - GW1_20240320

WELL CONSTItU('I'ION RECO (GW-1) ( '
For Internal Use Only: r
1.Well Contractor ;y ,alma:. • -•
Well Coatnctorximo', • • ' •14.WATER ZONIS"..' • I 1 .
.FROM 'TO • DESCRIPTION - .
•
. NC Well COelractorCartifcitioaN . " • tt f4 I
15.OUTER CASING(for multi-eacll'ed n eW OR LINER(Woo Ruble)
•FROM TO: DIAMETER I TSICINISS MATERIAL
company Name ' • tt ll
',� 1 ld
2.Well Construction Permit'#: 1/l/ (+p 0 �/ 16 INNER CASING OR i TUBING(geothermal doled-loop)J All. [ O I.�-a _ do2 3"PROM TO• DIAMtrZR THICKNES ,
" prl ail appllca6k well eonrtrucrIon permits n r.VIC Couny.Slate,Variance.sic.) 4/ f- 7 d" •- S 7 MATERIAL
3.Well Use(check well use): ' R ft l / //l�r p�L",;..'
ft to.
Water Supply Well: • d7.SCREEN
❑Agricultural. •• Municipal/Public•" PROM TO DIAMETER SLOT SIZE •THKCINLS9 MATERIAL
OGeotheimal(Heating/Cooling Supply): tt ft - to
-identiel Water Supply(single) ft
OLidustirial/Commeroiel Residei►tial'WaterSu Supply y( d). 1'• ;
Olirigatio{i - is.GROOT i; ,: _ , �,
❑Wells>100,000 GPD -• FROM TO MA • ,
Non-Water Supply Well: • • d ft y In>pllclbnun METHOD AMorINr •
[]Monitoring '. DRecov, / e<.f',r �/) .Y i.•l.`.
Injection Well: i<
• (. PorTi9i�,,t• p�,- ( -
OAquiferRechargo ❑GroundwaterRemediation - tt
=
❑AgwferStorage and Recoveiy` inity OSal Barrier• • 19.SAND/GfyVELPACE(If applicable)
❑Aquifer Test, t PROM To MATERiAx• EMPLACEMENT METHOD
OStormwMer Drainage. ft. ft• .
DExperimental Technology / ❑Subsidence Cantu/• - ' .
ft R -
RGeothermel(Closed Loop) • �� []Tracer • ' •
. ' ❑Geothermal(fieating/Cooling Return) ❑Other(explain under#21 Remarks) PR DRILLING LOG(attach additional Sheets if necessary)
FROM TO DltSQiiQ11QN fcder,b.rd.sa,wWnek type,tole act,.ere)
4 , Wells)Co ,3�/3. P�f •
ft rrZ
.Date mpleted• Well ID#
Sa ell Location • • ft •ft K
Facility/Owner Name I - • F�►ym1(if.PPhcable). ft. • ft. I�I:,• -i ll• cu24
Ll fr?P Roc tr ea r r ,aA • - ft
"3 : •a.L
Physical Address,Ity.aed Zip �ft4n?�,ri"tu•Qc^-1 •' a i
/ � ;;�. 21.REh1A1tKS . .. ft. , u 3'X
Coualy� • POrce1IdentiEcafioa No.(PIN) ,• r +.
5b.Latitude.and longitude in degreea/ntingtes/seconda or decimal degrees: • i .
(if well Sold,one 1st/king is sufficient) ;
c 1� f • 22.Cerflfi
I� d N �36 W ./ ".-' :.13 •
Z .
6.Is(are)the wells) �Permanent or .❑Temporary d f Q 3igadtme bfCEitifie$> Coahactor ;
• 7.Is this a repair to an existing well: DYm 'fir '' o'•, , ' By tgningthlsform,Ih
. , ; .�,. LrC CON •' ..
OTC arIS JiCA 02Cgoo tha200 Wwm�
• lJANGC dhas b e orovi NCAC 0100!Yell tuuucUon St a��,
If this Kra mph;fill outlknawn;yrL corutruction Gyornration aid a' the naturi olds of ail record?ea(seen repair under I7!remarlt sec/on or,on the backofthisfoi'ns . W?!l�d to ma wsL owner ;
•, • •` • ." 23.Site diagram or additional well details '
S For GeoprobelDPT or Closed-L•oop Geothermal Wells having the name . • 'You may use the back of this page to provide additional well construction info"
construction,only 1 GW 1 is need, Indicate TOTAL NUMBER of wells • (add'See Over'.in Rdinarb Box).You may,also attach additional pages if nr ary
drilled:
' 24.SUDMflTAL IINST1tU ONS ' .
. 9.Total well depth below land surface '-` a.3,i i (ft)
For multiplew.eltrUrto/ldepdu. .. .•r„teexwnple-3Qto0'wd20a1p0� SWiroltthisOW-lwithin30daysofwellcompletionperthefollowing:
10.Static water level below fop of casing:' • • 24ar For All Wells: Ori fo '
Ifwartylevil is above earl,i use.+� " • 8� m1 tO Division of 7699 RCSOUroeS (DWjl),
, If Infcimatidn Processing Unir;1617 MSC Raleigh,NC 27699-1617.
11.Borehole diameter • G I a • (in) 4n- • 24b.For InlscH Wells;Copy fo D `
• .. . . �,Un derground Injection Control(lUC) • -
/I Program;1636 MSC Raleigh,NC 27699;1636
12 Welt construction meshed 'o'f Z a r.
CLe wtt�.mtuy,table dcectpiub,etc) • 24c.,For Water Supply and Open-Loop GeotbermalRe(uii Wells:'Copy to the• county environmental health department of the county where installed=
FOR WATER SUPPLY WELLS ONLY • � t � '
• 24d.For Water Wells prodddag over 100 000 GPD Copy to DWR,CCPCUA 13a Yield(gpm) .. 2V • Method of testa' • •• •
Permit Program,;1611 MSC,Raleigh,NC27699-1611.
13b.Disinfection type H T Amount: - 4
� v ",{
Form GW-1
North Carolina Dcpartmaot ofFuvirdnmenld Quality-Division of WaterRedouucoi" }I , • e._.-•• - -