GW1--02236_Well Construction - GW1_20240408

.
• WELL CONSTRUCTION RECO (GW 1) For Internal Use Only: • s •, '
•
1.Well Co r•Information:
I i •
14.WATER ZONES
- Well Co ctor FROM TO D!SCRIPflON
. `f5-974 • . •• /i0 it. iz� tt
' NC Well Contractor CeniSeuIaaN/fumker ' • . .
.1
� /'�/� �,�� � J 15.OUTER CASING(for multi-eased wells OR LINER(if ap licoble)neteniaet Y p 4)�X/V‘ FROM TO - DIAMETER THICKNESS g MATERIAL
Company Name ••
I R I .• � I
2.Well Construction Permit#• fJ l 79,- r• 2 3 16.INNER CASING OR TUBING(geothermal dosed loop)
FROM TO DIAMETER - THICKNESS MATERIAL;
List all applicable well constructionpennits(l e.UIC.Count',Stare,Variance,eta) ft.
ft'
3.Well Use(check well use): ft. • ••g • j; ', in. P .
Water Supply Well: •
41-SCREEN r
°Agricultural OMunicipal/Public FROM TO ' DIAMETER SLOT SIZE THKCINESS MATERL4L -
ft. ft. in.
°Geothermal(Heating/Cooling Supply) sidential Water Supply(single) "
(si g ) tt ft in.'
Olndustrial/Commercial OResidential'WaterSuppiy(shared) • •
hri tro 18.GROUT
O
ga' n--- -_.dwells>ioo,000GPD _'. FROFfl • TO MATERIAL }MPLA.CFMENC METHOD&AMOUNT
Non-Water Supply Well: [//J fe ,/
°Monitoring . °Recovery._ �, fe ��t i[ t�YLt�. ,
Injection Well: .. , . • V tt 1
w
• ' °Aquifer Recharge °GroundwaterRemediation '
OAquiferStorage and Recovery [7SalinityBarrier 19.SAND/GRAVEL PACK(if applicable) • •
FROM I TO MATERIAL 'EMPLACEMENT METHOD •
. °Aquifer Test .• • OStormviater Drainage
°Experimental Technolo • •gy
gY °SulisidenceControl ' ft'I R r
°Geothermal(Closed Loop) • OTracer
20.DRILLING LOG(attach additional aheeb if necessary)
•°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) PROM ft. TO' DESCRWTIQN{odor,tuvdaw,calif rk type,grata six,etc.)
4.Date Well(s)Completed: 3- Z•5--L`fweu ID# • .ft. •it
5a.Well Location: ft. fe � as t.-,;„.
• �eclis AAuI1�OZ •
n r� x
Faculty/ wnerName • Facility IDx(if applicable) ft. f< A Nir R %G `t
Physical Address,City.and Zi ft. • ft ', tC
d'{e h . . . , 21.REMARKS%• . '
' ty '
Parcel Identification No.(HIV) j'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: "
• (if well field,one 1st/long is aittlieient) 22.Cer'
• . 1
- '3.h' - r 4 , i ' N .53b t 1/-7 ' 2 W _
3=2
. - '6.Is(are)the well(s):.°Permanent-•-or--°Temporary • Signature of C jfie.4".
11 Contactor, Date
Bysigning thirjome.Ihereby eert(fy that the we I(s)war(were)constructed in accordance with ,
7.Is this a repair to an existing well: °Yes or j�`lo• 1SANC4C 02C:0100 or 25A NCIC 02Ci.0200 Well Construction Standards and that a copy
lid*isa repair,fill out brown-well construction information mfdexplain the name oldie of this record has been provided to the well owner.
'repair under ii21 remarks section or on the back of this fonts
23.Site diagram or additional well details:' ' _
S.'For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same . You may use the back of this page to provide additional well construction info _
• construction,only 1 GW-1 is needed. rlcs Indicate TOTAL NUMBER of wells (add'Sec Over'in Renia Box).Youmay also attach additional pages if nrricay,
drilled:
q 24.SUBMITTAL INSTRUCTIONS
, , 9.'k'otal well depth below land surface:'• t. L O (fl) •
,
Formultlple wells i/sr all depths if different(example-3(a)200'and 2(urJ100) Submit this GW-1 wllhin 30 days of Well completion per the following:
10.Static water level below top of casing: V Q • .(ft) 24a. For All Wells: Original form to-Division'of Water Resources (DWR),•
Ijworer level it above easfng;;we�+� f Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 • •
11.Borehole diameter: !' •Cm•) . 24b.For Injection Wells:Copy t• o DWR,Underground Injection Control(IUC)
Program, MSC,Raleigh,NC 27,699-1636 -
• 12 m
Welt • Poi ail. !i ,
(1.e.,auger,rotary,cable;direct push,etc.) 24e.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
•
•
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
r'
•
•24d.For Water Wells produdngrover 100,000•GPD:Copy to•MR•,CCPCUA
13a.Yield(gpm) , 57. Method of teak .• a_,�,,, -• Permit Program, MSC,Ral •
..
eigh,NC 27699-161 T r
13b.Disinfection type: ik f Amount: ..
•
. .
w
' • i • .
,
Form OW-1
Department. -Division of Water Resources , : . . `