GW1--02121_Well Construction - GW1_20240405

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il, CTION IIECO. (GW-1)
For Internal Use Only:
• 1.Well Con. ` •,ormation:. i; .._.--
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•14.WATAR ZONES . ,
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Well Cann •
al.i„o PROM
TO DISCRD?TION
5 l 7./-� 15b • a10 ft. i, I ' ,
NC WellConbeetorCe+tiSeationH ft. fur•
u I(n•_ Q���J 15.OUTER CASINI,(for multi eased wets OR LINER(if ap liable) •
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•FROM , ITO .
• I DIMMER TRIl�RS4 j .
Company Name �l !t ft. in MA7LRIAI,
2.Well Construction Permit'#: ! D - !- / • . 16.INNERCASMGORTUBING(geothermalelated-loop) .
2. o!/ Construction
n Permion PROM• TO DIAMETER TRICicNrss MATSRIAL "
penal!:n m WC Cotmy,Slate,Variance.eta) ' R ! ?tt In /
3•Well Use(cheek well use); +� r'2J ;5 7�a ' ��7 ark:. /� �[�_
ft ft q in. / •
Water Supply Well: • 1'
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.17.SCREEN '
• OAgriculbraf,' • , . • 'OMunieipol/Public• PROM TO DIAMl1Rg SLOT SIZE TBG�IfSs MATERIAL
calla ft. ft. _OGeothermalin. • •
• (Heating/Cooling Supply) -tidentird Water Supply(single) • •
OlndustriaUCommerciel • identiel'Water Supply ft R' in'
Okrigatiop uPP y(shared) la.GROUT
OWel s>100,000 GPD FROM TO
Non-Water Supply Well: >�ucrAnuvrMtrraoa&AMOUNT
OMoaitoring_ • ft -
4,Recovezy ft. . r d n �'/�� .
' Injection Well: ' • l ft. 71/l JG
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' °Aquifer Recharge, • OGrou •
_ndwaterRemediation tt ft l/ •ae�
OAquiferStorage and Rtxovery ti OS - 19.SAND/GRAVEL PACK(if aprUcable)
elifldy Barrier •OAquiferTest; PROM To: MATriRIA2, .. sbi[,►cnurrn METHOD, . OStomtwaferDrainage + • ft
OFxperimental Technology• •OSubsidence Control' ' ' • R R
l]Geolhemtal(Closed Loop) '. . OTracer ., • " '
'20.DRILLING LOG(attach additional cheek if necessary)
OGeothermal(lieating/Cooling Return) OOther(explain under#21 Remarks) MOM TO • DtscRIPUON fnlar,Amine",ft eo.uWndc hpa.vain me.ate)
4.Date tp . ?
Well(a)Completed: 3-2' Wen Di# • ft. •
tt ft r
r•• ICh?�(r r Mc 1 f , AP,E
Facrlity/OwnerName• ' U t�:'GQ��.' '
FacilitYll)il(ifappliea6le) it. R"
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bri , dare.,,City,and Zip P tt,
l'Jl f J L(YC1.t -21.REMARKS/ 't,. -,
County J �' Rural 1'
a Identification
56.Latitude'end longitude in degrees/nunutes/seconds or decimal degrees:
(ifwell Sold,one 1at/long is sufficient) '
'7/ t 3 b t• 22.Certifies o
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6.Is(are)the well(s): Permanent or OTemporary ' 3 0/t, t. Sigoahue ofCr tiiieffi�Sla l Contactor
Data
7.IsthlsarepairtoanBysignIngth6jonn,lherebycerrlfy that the wetl(i)West(were)constrUctedinaceordancewfth .
existing well: . Oyes or . No 1SANC4C 0JC:0100 or'7S:tNCIC 02C.0200 Well Cpiatnaton Standards and that a copy
lfthlsIra repair.fill an known well conrouctlon'Inrormailan the nature oft e 'aphis record has been provided to thews!!omen:
•repair ander 121 remarbsection or on the back ofthisfomm. •
23.Site diagram or additional well details:8.For Geoprobe/DpT or Closed-Loop Geothermal Wets having the same" • You may use the back of this pogo to provide additional well construction info
construction,Only 1"GW1 is need Indicate TOTAL NUMBER of wells (add SeeOvef inRtmarksBox).Youmayalsoattachadditional
' drilled: pages ifnecessary • ' •
At 24•SUBMITTAL]NSTRUi IONS ' • •
9.Total well depth below land surface: 'dt �Q.
Fir multiple wells list all depths lfa eat(example-9(aj200 mndTQl00� (f e) Sulimlt this GW 1 within 30 days of well completion per the following: ' '
10.Static water level below top• of casing:-•. �j'f7 (f`).•
241.'•For AA We1Ls: Original fo to Division of Water Resources
lfwaierleveltsaboveeariny:uso,�l` InfcrmatidnPincessiheJnit,1617MSC,Raleigb,NC27699-.1617 ' � ), ;
11.Borehole diameter % ,
(in.) . 24b..For Infection Wells:Copy to DWR,Undargmund Injection Control
� /; Program,1636 MSC,Raleigh,NC 27699 1636 (NC)
, 12.Well construction meWod • 11 0 l a.lti1 f�t-t^• .i
(te auge,mtuy;cable,anent p,tch,eto) 24c.,For Water Supply and Open-Loop Geothenl iilrefuiiiWelk:•Copy to the •• . county envimnmcnte'health department of the county where instated c
FOR WATER SUPPLY WELLS ONLY: ••
22 • 24d.For Water Wells proddcin;over,100 000.GPD:Copy to DWR,CCpCt1A
13a•Yield(gpm) J Q' Method of test: �(�� Permit Propram,1611 MSC,Raleigh,NC27�99-1611
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13b.Disinfection type: , l /l Aino• mt: •
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Farm GW 1 '
North Carolina D'varment ofEuvircnmenlal Quality-Division of Water Resources '' . , r_':.•. -.