GW1--05952_Well Construction - GW1_20241009

'WELL CONSTRECT.ItiN'IitCORD(GUT4), For Internalvio-Qnly! ---
Wellop:aiCO'Information:, ,.. , '. • • - ".. " --"--- - --- •
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- FROM TO - . -DESCRIPTION,•
Welibciiiiiatof Nuns
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Nornber,:,, . ,- .. sii,015T)ER:CAS-174G'(Icir.ritulti-eas. ed:wells')OR LINER(If an lienbli):-.-
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2.Well Construction Permit!!:- 1 ;.'•-!;''' -I,3(2,-.(1 •_.;..._ • i'eltie. 1') FROM TO, ' -- DIAMETER- ' THICKNESS` MATERIAL
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3.WelliTie(Cheek:Well use): , • ft., • 'It • , •in. ; -
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!".„Stipply:WellV,' '
FROM 'TO:--' DIAMETER SLOTS . THICKPIESS MATERIAL
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9Geoocimaimeatiwtoolitig§OPPlY.)iiieSidentiat Water Supply(single) ft.: - ft.. / vo
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• ['Residential Water Supply(shared) .:18.GROUT:"..f.;'."."-2-".:,'-.-.t'•,‘-•-°-•••••,•:'•.. ,--- • . --,: - "- •,::-..".t,-,-- --„,:-,:t611.:',;;.‘ ,::'',1
irrigation . E1Wells>;100,000 OPD . . • FROM TO ' - -DIATERLII;ft .. -EMPLACEMENT METHOD&AMOUNT
. : '•:. Non Water Supply Well: •-•
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DAqulferRecharge . uva er- eitidiation. — - _ - -- • _ . _ . -------7- - —--- —
19:SAND/GRAVEL,PACK(if applianble
pAgitifer Stowe:IndRecovery Ogaliirity Barrier FROM ' TO MATERIAL 'EMPLACEMENT METHOD
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,1;14q4C*-tsi 13Sferinwater,Dminage 4.0 It' it ,
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ClExperiinental•TeChnology- pSubildence Control 'ft.' , ft.
ClOcothermal(Closed Loop)' ( Tracer. •• 2VDRILLING.LOG(attneh addltionalibiets if neieseari) ,z. .- 7,"'...
',13Geathermal(Heating/Cooling Retusii). bOth'er(explain under 1121',Rehmiki), f FROM
1:' TO ,--.!E"CC°IPTION(nnl°14 hinInflf."Wind'°Pr'grain tire etc.)
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4.Date IFell(s):ComPleted•''' ''''/;";:• C-if"Well 1D0'
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F ility/Onner Maine • ' y tity IDIf tit applicable). '" .14
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griv--:-as-ito q 6 9= , $4, e' it '7-1)
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4ysie6 Address City pad Zip, • ;ft.. : - It; '-".• • ' • • ' ‘ti,,,„_,,S,'t-,0-,,,t.-- ''-..:,-.7-1•'".-' - •.,,t •:;',-7,,,,::-.,-,4
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',644t "• •Piutel IdentifiCailisoNo;(pIN) .("e` -;//L7-'i'd. . .'. 1--%---_)---/ .- 1--- . . ..',
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5b,Littitutle and longitude in degrees/ininutes/seConds or decimal degrees: -_, ., „ . • ''. ,
(it well.Eeltl,nn41/Imi is sufficient))' Cc rtlficatin - - : ;, •
D?'- 19 N 1720' 1-6... - .33— w . . . ... • , ,
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6.Is(are)the Ar ermanen !t,, or ['Temporary i I led we2„....)r tor• t'
. • Agnew ihistifirrn,,,flie;e0yeeila!ihriii/re tre/l(s):iim-titivie)eciirditiiil la air4skiirce with
7.1a this a repair to an existing well. ,,,[1'Yes'.-or Pifl' ..! 1.5;,1'.WCAC'.igq:010D'Or..15.4 NC...IC Nqc.oioo le41,4astrziallon,Slandards and that a copy
If this Jr a repair,fiber larown well coariniaida Info ale!nnationexpIaln the nature oPhe. oft/its record has been provided to the iiykoivafr.
repel.a...* 21 ;:;:arir tutalan or aa•tkeb.*of thtf forat.. - .'---1
23:Site ditigram'or:additionid Willsdetalls:'8.For Geoprobe/ElPT or Ciosed-Loop",Geothermal Wells having shMa, You:may use the back of this page to provide additional.well construction info 4 ,•:1
v t
construction,only 1 'GW-1 is needed:-Indicate TOTAL NUMBER of wells '(dd:Seel:yeti,in:Item:Ail:Mx):Yon may.aLso,attach additional pages if necessary.. 1 =
drilled: _ ... .
24:-SUI3AIITEALINSTRUCTIONS
..., 9.Total Weltdeith.below land surface:••• • ' '- - -', • - ' ,,,-
•- - . • . . pt-- ,
Fol.:multiple'wells list all dipihs Vdrerent( mpte,,Jwoo.f and @loop ' (ft•-) Submit' thisOW.Ttwithip.Stl'slaY'siif,W•ell completion per the following
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R"'"'"' , 24a.-Far.All Wellsr.briginel.lomt.'to Diyision of-Water Re.stiurcea'(DWR), 1
10.Static Water level below fop of caging: _, 0.: .
vtl In coirnatipn,?rponAaing-l.Init;,.1017,41.6;itateik,li,NC 27699,1617 ' 1
11.Borehole diameter: ti •"(in) 24b:For Infection Wellsi'cop •tikDWR,,Underground Injection Control(liJC) r
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12.Well construction method Al 14/,'-- -i 0 - -ik:—_,./ Ai Prograin,-1636 MSC;Ralei ,,K 27699-1636.
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• 24t.-Far NVater Supply znribpen-toop Geothermal Return Wells f Copy to the
(i.e auger;Mini;01#;,..flirea-pusb,sic) county environmental health department of the county where installed•• .
- ..
TORWATER'SlIpPLY:WELLSPNLY: , ! • _• -
Copy to DWR,CCPCUA
24d,Mir Water-Wells producing over 100,060 GPD:•c -
,
Permit Program,1611 MSC,Raleigh,NC 27699-1611 - -
t., : ‘.-•....
13a:_yield:(gpini 03.. ,Method of teat:- i4 fl .•
130.ojstiifeeilon type: - ... ; ',- Amount:
6
Form GW-I North Carolina Departmenfof Environmental Quality-DivisionorWater Resources ReViSed 6,6-2018
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