GW1-2022-00166_Well Construction - GW1_20221219

WELL CONSTRUCTION RECO GW-1 For Internal Use Only: .
I.Well Conbractor-information:
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• S. , l-eh e q a� 14.WATER TONES
WIC-atrachuNm, 11LOM TO DESCAWI9ON
3 s3s 0 C fL � isR R
NC Well Coatraesor Caddaadm Numbw
� ��)� 15.OUTER CASING formuidaasdwells OR LINER if. Doable
I LUA r 'A{ FROM TO .LSIHEfER THICJ0N63 MATvuL
Company Name h ft in.
D9I 'J 7 , /1 16.INNER CASING ORTURING eoMermal c1m2d400
2.Well Construction Permit K: c7— v" FROM TO DSA ., THICKNESS MAXIMAL
ListaOappilwbie wdi wrwhrwlonpstnrlcr Q.a UIC COMM Slate,Var(mc,aIq D. .Sr1 JJ (t ,d/ fo. Ch. ✓Ci 3.Well Use(check well use): ft R -io.
Water Supply Well: 7:SCRERN
OA cultural FROM TO DIAMETER SLOTSIEI THICKNESS MATaW
�' 44MllwicipeUPublic tt fL id
OGeothermal(Heating/Cooling Supply) widential Water Supply(single) .
dd ft. fG � to
O m lndustriallComemial Rgid-,W Water Supply(shered) IS.GRODT
Okri lion OWells>100000 GPD FROM To v*acrsr nlnutSAmTMElRmkAMOUM'
Non-Water Supply Weil: Q hL3 R ea Y�
OMonitoring ❑
Injection Well: Recovery R h ;ar
OAquiferRech ft ft
OGrolmdwater Remedietim
OAquifer Storage and Recovery OSalulity Barrier . 19.SANDIGRAYELPACKda tieaMa
FROM TO MATERIAL 110IACEMIEWMETHOD
OAquifer Test OStormwaler Dminage tt R
OExpmimental Technology OSubsideae Control- ft O.
OGeothermal(Closed Loop) OTneer 20.DRILLING LOG aroch addi'coal sheeb if necessa
❑Geothermal(Heatin&ACucling Return) OOther lain under k21 Remarks now-R To nE9cnmTON .vier aud. ..a/ — ate.
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4.Date Well(s)Completed: 1 Z—I—Z Z— Wen 1DN ft .&
52.Well Location: R ft
,lUt ICha e ft. it .
Facility/Owner Name Facility IDa(ifoppfieable) ft R. .
42►— Scxr, Ad 13osl�-1�1.I.9 Rd tt h
Pbrsical Address.City.ad Tip R� ft .
21.REMARRS
C—ty Parcel ldeoti8tationNo.(FIN)
5b.Latitude and longitude in degrees/rninutestseconds or decimal degrees:
(ifwen field one ladloug is sufficient) 22.Certification:
W I2-IZ- 2z
6.Is(are)the wen(a):lerenanent or OTemporary � +� / Si fC ' "Well Condor Date
B5AA rAC 02C.
2Corm,0 or'75 eerafy rherlM well(i)war(rue)rauoacrrdln aamdonesw(N 7.Is this a repair to an existing well; OYes or j1fNo ISO NCAC 02C:0I00 or IJAhGC 02C.0200 We0 Consf-coon Stands dr and drat a copy Ifahl'lranpa(rA➢oesk"an wflwamacdm Allbrenodon andcgWn th.mtare ofthe of0de .wrdhas bccnprovldedto the well owner.
'rspo r order 021 remarb seeam arm the back ofr(rtrfmn.
23.Site diagram or additional well details:
S.For GeoprabHDPT or Closed-Loop Geothermal Wens having the same You may use the back of this page to provide additional well conatructlm info
construction,only 1 GW-1 is deeded Indicate TOTAL NUMBER of wells (ace Over'in Remulo Box).You may also of ch additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (,A6 t (ft) '
Formalt/ple we0s list all depthr lfdoeredr(erampie_3®700'm d2(r)II00� Sub ak this GW-1 within 30 days of wen completion per the following:
10.Static water level below top of cuing; I (tt) 24s._For All Wells: Original form to Division of Water Rueouroes (DWR),
ffwater level Is above wsrng rase•+• Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/ 1
11.Borehole diameter. lF 0 ,gym,) 24b.For Injection Wens:Copy to DWR,Underground Injection Control(RUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:��O"I a FH —/t7 '
(Le.Sager,A— ,cable,d'axt push,M.j 24c.For Water Su 1 and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department ofthe county where Ted
FOR WATER SUPPLY WELLS ONLY; 24d For Water Wens roduein over 300 000 GPD:Co Eo D py WR,CCPCUA
13s.Yield(gpm) /L. Method of teak l� Pm°It rogram,1 Il MS Raleigh; 276 9-1 11
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13b.Disinfection type:, Amooak s✓
Form OW-1 North Carofmt DepMroml offiam mood .Quality-Division of WatarResomwa