GW1--05639_Well Construction - GW1_20240916

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WELL CONSTRUCTION RECO •• (GW-11 For Internal Use Only
1 Well Contracts ation: • •
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14.WATER ZONYS !
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WellCoobaderName • FROM TO i DL4QtI?ION •
5 �^� %D0 fL' aAt9 I't' . • , . • .
R. IL
NC Well Cati5ationNumbes
Y J r 15,OUTER CASING(for mold-eased welt OR LINER(if ap arable) . -
. t.LU ► / r ill'•�Ij S mom 1•iO I DIAMZIIIt ) 18tQR7iSS MArt[UAt, .
Coatpany Name
2.Well'Construction Permit#: l '.1 1 v V. I L ER CASING OR TURING(geOthermat dared-laea) .• -
DlAbILilit TSICKNL45 nfATQwL •.
.Ulf all applicable well eamminrclon parodic(Le.UIC Colony,Stare,Variance,WO 1• IL I :1. '(r to
3.WellUse(eheekwelluse): (t, n, k J
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Water Supply Vl!ell: 417.SCREEN
FROM TO I DL4Mmle SLOTSIZZ vnzac zss alA7ntrAI.
- OAgricultuiel OMuriciped/Public
nl i - br
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OGeothexmel(Heetirig/Coolingrupply) dentiel Water Supply(single)' -
tG
OlndustriaUComuneaeialdeatidWater Supply Oared)
1ti.GROUT
°Irrigation OWells>100,000 GPD FROM ' TO ' M,t7TRMAL • nAPLACIMINTM�0DStAMouta
Non-Water Supply Well: . ' • 0 Z3 ,yt N y
°Monitoring ORecw 7 • , .- ••)c e i ' .
aY • to • tt
•. Injection Well: Ot"Y r�/l ' . P t
°Aquifer Recharge ' OGroundwaterRebmedintion
OAquiferStorageandRe>cov II SAND/GRAVEL PACK(If appl applicable) ,: • ' • ' -,. "... ,
Recovery . OSalinityDerrier FROM • TO I,, MATERIAL " V inWMCIDIENTMETHOD
OAquiferTest OStormwaterDrainage
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OExpenmentall Technology °Subsidence Control ft R
OGeothetmal(Closed Loop) °Tracer
20.DRILLING LOG(attach additional drub if necessary) ' '• •
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OGeothetmal(�Heating/Cooling Return) •°Other(explain under#21 Remarks) FROM TO DLSCtritlION(tiler.twieesr,wa/radc type.srai shq etc) r
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4.Date Well(s)Completed: 1 Weds
ID#
. • • Si.Well Location• R iti
C. b-f} S ch lAU e►-t"L ! n ,,,-
Facility/Owner 1: 7 +_.r°", a e fS" ,
FaalityIDtr(tfappfiablo) . ,"• n. ft r':E aa.•s ,i... 'J.t...Li
� �� h a 1, 46114 Su(-Pit I. III •..,t . ; . It:
�it0r=..City.sod ZipI 1 1 SER 1 u 20?4
P� VV AIL, •
• 11.REMARILS! If:�.a:n.,`• a e,:. s i'
C0e°y Paal ldeatifiation No(PIN) G •
d c t.ti�`�.r�
{ IIl
5b.Latitude and longitude in degrees/Minutes/seconds or decimal degrees:• 1 •(ifwell field,osufficient)e lading ii sufficient) •
32 'Jo / ' Serif Si ' / I I , 22.Cer' _•.
6:Is(are)the well(s):)(Perm-anent or OTemporary, ' _ S' of 1 e&1,Conhactor Dab
IZ�o
7.1,this a repair to an existing well:: l7Yes 'or • ' By signing►hdjonn,Ihaebyeernjyrhat the well(,)war(were)ea�avuedtnoaeoidmtcewlth
I r S this
No. ISAN.;AC 02C:OI11O or•ISJI N AC D2C.0200 Well Catnap:don Standards am!that o copy
f repels,Jill ad Ibroim well connivance*Inforatanon avialn the natiatr•of the of Oil record lace been Funded to the well aims; '',repair trader DJ nano*moon or on the backofr%1,1:ja ,
23.Site diagram or additional well detaWr
8,For Geoprobe/DPT or Closed-Loop'Geotermal Wells having die steno You may use•the back of this pages to provide additional well consttuc in info
• '. constriction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Rtrc rest Box).You may also attach additional pages if ne j;
drilled:
24.SUBMITTAL INSTRUCTIONS '
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9•Total well depth below land surface: 1) (IL) I =`
Far multiple wear an all deprhs Ifdtfjerent(exanwk-3�00'and:Waif) Submit this GW-1 within 30 days of well corn letioa- p per the follewiag•.
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10.Static water level below top of casing: 24a. For All Wells: (Menal form*to Division of Water Resources-(DWR)
limner level is abort earhry roe-+- : �/ ( ) Information Ptoeessing Untt,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. '�( v �) 246.For Iuleetion Wells:Copy to DWR,Underground
1 Progrnm,1636 MSC,Raleigh,NC 27699-1636. Injection Control(lUC)
12,Well construction method: ' a ( a r-t A I Y- . .
(ia auger alum cable,died peat,eta): 24a For Water Snoplyand Open-Loop Geotheriaal Return Warn Copi to
county enwronmentnl health department of the county where Installed
• - FOR WATER S[h'PLY WELLS ONLY: •. li.
13a.Yield(gpm) /� 24d.For
Water Wells prodacisc over 100.000 GPD:Copy to DWR,CCPCUA
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Method of test: /mot i.i' gi�.1611 MSC,Ralergb,NC 27699-1611
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13b.Disinfection type: ' I Amount: vt%
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