GW1-2022-10681_Well Construction - GW1_20221205

7N�
WELL CONSTRUCTION RECO GW-1
.� For Iatelnal Use On
131
I.Well Coritrac rinforma�te;
•14.WATERZONES I
WellConhactorName MYL:
TO I DESCRIITION
3.53 5 '
NC Well Contractor CertiSeationN ft m ,
111IIYYYYY I5.OUTER CASING for multi-eased wells)OR LINER tf a livable
FROM I TO I i DIAMSrER THICKNESS MATERIAL
Company Name f6 ft �, is
37 f 16.INNER CASING OR TUBING othermal cloded-Too
2.Well Construction Permit#: v FROM TO DrNGMot •rg ged-loop
S MATERIAL
List all oppllcable well eonstrttctlon Pe It. (l a tllG County,Staty YaNancy etc) --� ft ft.*!.
t 51 1- "
3.Welt Use(check well use): ` ft ft in j'�j
Water Supply Well: 7:SCREEN ;
OAgricultmal FROM I TO I DIAMETER SLOTSIZE THICIWESS MATL�RiAL
❑Mrmicipal/Public ' ft ft i is
❑Geothermal(Heating/Cooling Supply) tResidentialVater
esidential Water Supply(single)
ft
❑IndtrstriaUCommeroial Supply(shared)
I&GROUT
❑Itt1 lion ❑Wells>100 000 GPD FROM To MATERrAL El1�LACEl17EtrrMEIHOD&AMOUAT
Non-Water Supply W-11 -' - - -ft Q
❑Monitoring ORecovery ft
Injection Well:
❑AquiferRecharge- ❑GroundwaterRemediation ft ft
❑Aquifer Storage and Recovery ❑Salinity Barrier . 19'SAND/GRAVELPACK ifs b'cable
TO EMELACEMENT
❑Aquifer Test ❑StormwaterDrainage • FROM ft ft �MATERrA L METHOD
❑Experimental Technology ❑Subsidence Control' ft ft
❑Geothermal(Closed Loop) ❑Tracer '20.DRILLING LOG attachladdi'onal sheets ifnecessa
❑Geothermal(Heating/CoolingRetum) ❑Other lain under#21 Remarks FROM TO DESCRD'IlON color hnrdoes:soiurock in AD,etc.
. ) ft • . ft ''•
4.Date Wells)Completed: �(� 'ZZ Well ID# ft tt
Sa. ell Location: ft ft
Facility/0 erName Facility3D#(ifapplieable) ft f` '7' t�, i� '
'Bn)w NA . Rd r; l o ��11�-�-.-, -it ft -
PbysicalAddress,City,and Zip ft ' ft r^.� ur.11
1'1 y111�. 03a 0G
TU AL�t� 21.RZNL4P9S! In 01�JQ1�
County Panel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
I ,
(ifwell field,one lat/long is sufficient)
.• 22.Certification: �
�- $d ' 2 8 /
N W -A��
� "_
6.Is(are)the well(s): Mp-rmanent or ❑Temporary 2 70 If _Signature owedowcuContractor-
DateBysigning thisform,Thereby certo that the wells)was(were)constructed in aceordancewith
7.Is this a repair to an existing well: ❑Yes or QNo 15ANCAC 01C:0100 or 2S;1 NCAC 02C-0200 Well Construction Standards and that a copy
If this Ira repair,fill out brown well eonstructlon Info
rmation and explain the nature of the of this record has been provided to the weff owner.
'repairunder#21 remarkssection oron the backof ddiform.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You m
drilled: ay use the back of this page to provide additional well construction info
construction,only 1 GW 1 is needed Indicate TOTAL NUMBER.ofwells (add Over'in Rdmarks Box).You may also attach additional pages if necessary,
r � 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
Forma/tiple welly llsl all de lfdderedt(example-3Oa 200'and 2@100� (f t) Submit tLis GW 1 within 30'd ys of well completion per the following:
10.Static water level below top of casing•. �Q ft 24a• For.All Wells: Original form to Division of Water Resources (DWR),
Ifwarer level is above eosin&;use"/+^f (l ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: a (m•) 24b.For Infection Weps:C�py to DWR,Underground Injection control(IUC)
Program,1636 MSC,Raleighl NC 27699-1636
12.Well construction method: yr
(Le.auger,rotary,cable,dixectpusb,etc,) 24c.7 or Water Supply and Uoen-Loop Geothermal Return Wells Copy to the
couny environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Watet Wells prodnrrne ove r 100 000 GPD•Copytto DWit,CCPCUA
132.Yield(gpm) Method of test: V ' Permit Program,1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type:
Amount:_ /2t ft-
Form GW-;l Hard,Catolina Department ofEaviromnental Quality-Division of%terltesotuces
f f