GW1--02608_Well Construction - GW1_20240426

. . WELL CONSTRUCTION RECO (GW-1)
. For Internal Use Only.
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•
1.Well Contractorfuformaflo ' ( , .
Idow a� y
14.WATERZONiS
Well Contraetoi-• PROM TO DESCRIPTION
'' NC Well Coatreetar Certification Number •
D-
n 15.OUTER CASING(for multi-eased wells OR LINER area Qnble) _ •
VT�ti .. PROM TO . •- DIAMETER THICKNESS
MATERIAL
Compaod•Name tt I I to
r q • • IE.INNER CASING OR TUBING
. 2.Well Constrretion Permit fi: - . '• O is) . ! -$ PROM "TER RICHNESS - ,
Dot opopplicable well eatsnua/onpermit,(!e I1IG Cony,•Slat;paricace ate) iG TO DIAMETER THICINE39 MA77tRIAL
• 3,Well Use(cheek well use): ft ft. t S'r /! 0 e •
lYp ..
Water Supply Well: ,- • 17.SCREEN . `, � • .�`- 1
DAgriculturnl DMKaicipalIPublic PROM TO DIAMETER• !srorSKzt THrCiNt[S9 MATTtItrAL•
OGeotiiermel(Heatiup�Cooling Supply) 6Reside al Water Supply(single)/ n. •R h 'Omaustrii /Commcre� bReiden tialWaterSupply(sl le GROUT -1.4f
Okri a hoI Dwell,>1.0o00.GPD .- . - -PROM'. , To - MAT1RIAI. manACsaai+rbalaon&AMOUNT'Non-Water Supply Well:• • . ' • O ft. /4 0 .
:'' An
OMaaitoring DRecovery !r`'� d t'
• Injection Well: • Dlrl r
OAquiferRecharge ,. • °GroundwaterRemediation '•• , `' ' _ ' 1 µ .
OAquifer Storage andRecovay , OSalinityBturlyd D.SAND/GRAVELPACK(iiapplicable) , .. • , . . ,
OA uiferTest PROM TO •. . ttfA•IPRIAr. atipLimssfeaR'MiIHOD -
• q � pStmmwaterDreimga' � !G m :�..
t OExperunental Technology . • OSubsidc•nco Ccnlrol' R R
OGeotfiermal(Closed Loop)• OTracer t
'•` ` •20.DRILLING LOG(attach additional sheeb if necessary) •• ,-
OGeothtxmel(lleabng/Coohng Return). OOther(explain under 1t21 Rem PROM TO DESCRIPTION(nby bantam,a0/ndc arks) We,Pais sac,eta) .
4 Date Well(s)Completed # /(sue ' • • is.
Sa.Well Loeationo ft fti. 7,+ Q � , , 1 , J .
•
Fie>7ity/OtinerName S ��N s s • I; 4
Facility/04(ifapplicablo)• • tt R ' i, r '•; ,
&' Pr>I` l f • ft' i, • ►t c�
P City,and Zip • c ft. ft. ;' rI u ,L.47 • 2�2
°f VLL .' •JP ' 21.REbIARItS!
Paeel Identifiwtioa Na(PRE I' .•�, •• . n r '. • x
• • Sb.Latitude and longitude In degrees/minntee/seconds or decimal degrees:• , '
(if well field,one lat/ons is sufficient) . . ' .• . : t '
'� I / 22.CeKfifiafioti:
lrli:€:t,
6.Is(are)the Hells e . T/K(): jkP rmaneut or, "]Temporary' • ?t GI) r . 'Sigubne b ell Coahaemr D�
7.IsthisarepairtoanMistingwel: DYes or o• /•
�'der"I"g�'I'farm,IhoebyewryqrrAcirheweU(,J,ra,(vs;cJe,nnvaedh;oao;doneewlth
ISANCIC 02C:01000P IS fNCIC 02C.0200•Wel Cpnarycdon Mmida k and that a copy
./this isa repair fill out known well construction information and. alit the WWII eths - afd&recwdhes bempovided to the well owner'
,' •irpa/r'wider 021 renarb:eatloh or on the baekofthlsfomi •
23.Site diagram or additionaI well details:
8.For Geoprobe/DPT or Goied-Loop Geothermal Wegs having the same You.may use the back of this page to provide additional well constriction info' ,
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells ' (add'Sec Over in REmaKks Box).You may also attach additional pages if
' ••24.SIIBMPITALINSTRUCTIONS ' .
9 Total well depth below land surface (ft)
Formuhlple was Lit all depths((different(awmple-3®700'aid @►00 y Submit this GW.1 witblo 30 days of wall completion
Y per We following::
10 Static water level below top of casing: '' S
24a,For MI Wells: Original form to Divisim of Water Reno V►n1
t/water level rs above caring iaa'+• •(�•) Information Pam.(D�•�Y.•. .
�/ !using Unit 1 1 MSC,Raleigh,NC 27699-1617
,11 Borehole diameter. ,U ( �: ,Ny) ' ' , . 24b.For Injection Wells:Copy to DWI,U• t•
• ndergru•; : Injection Control(RTC)`Pmtgam,1636MSC,Raleigh,NC 27699-1636 12.Welteomfruetlon method )�O+ h - '
Cca mt•cs:able.died push,eta ,, 24c.For Water Simpty and O , .
`' `' '• :''' county eavironmedtal healthOven-Loop fthe county Return Wells:Copy to the*.
FOR WATER SUPPLY WELLS department of the county whew installed
O ILYr
13a.Yield(gpm) alto permit.44d.F r ater Wells p roducln over 100,000 GPD Copy to DWR,CCPCUA
56 'lifethed of test: '• alto . - t�n.1611 MSC,Raleigh;NC27699,-1611. • •
ti
13bD. Wafechon type ,14: t F '. .,
FortenWa ,t,