GW1-2022-00167_Well Construction - GW1_20221219

WELL CONSTRUCTION RECO GW-1
�� For IDtemal Use Only:
1.Well Cotitractoelafo lion:
14. '
���C�r�✓l.J�" . WATER ZON%S
Well Contractor N. FROM TO DYSCR ON
.+ L�J, I l'n� aril fl 26 R
ft R
all Couhactm(:md5ntiov ism
15.OUTER CASING for multi-cased wdtr OR LINER rta Inble
j/k/f PROM TO DGMC[LR I TRICIINI55 MATERIAL
mpmy Name
ft R v
16.INNER CASING OR TUBING eothermal elated-loo
2.Well Construction Permits: ���/ / FROM TO ardMETER 7RICWIaSS MATERIAL
LstaOappllable—cona~1onpnmirsix .IBC,Cowry,Sim,,,Parfmrce,eleJ .�. M G J 2 (t'
3.well Use(check well use): tt R in
at roupply well: 7:SCREHN
A cultural PROM TO .. DGMl'IIR SLOTSIZE CKNESS MATERIAL
! 'OMwicipaliPublic ft ft I.
Geothermal(Iieatinp/COoling Supply) OResideotial Water Supply(single) It It. in.
OTndustriaVCommeroial OResidwtial'Water SuPP1Y(sh IS.GROUT
OIIri tioD OWells>100000 GPD FROM TO TERGL EMFLACQ.RHf MEIROD A AMOUNT
Nou-Water Supply Well: U ft fL ea, .w of
OMotut
Injection We ORecOve
well:
ry R ft •\
DA uifer Recharge ft ft
9 °Be OGroumiwater Remediation
DAquifuStorage and Recovery19.SAND/GRAVELPACKda liable
DSallnity BElriW =7 '6.dp
RW, EMPLACEtawrNXTROD
OAquifer Test ❑Stormwater Drainage
OExperimental Technology OSubsidenoe Control OGeothelmal(Closed LOOP) OTraeer oval she<oi❑Geothermal(H lin Return) ❑Gtha lain 11ndQ s2]Rtmado) IPTION nior hardy iak iv ' etc.
4.Date Well(s)Completed: 17 -7-7.2' Wen IDs R .A
5a.Well Location: R ft
�.'-w, J n &- R ft
Facility/Owvc Name 1 ' Facility IDO(ifappinbk) ft. ft:
Lf2-1 II, N- V C�f�1l�sy �b( R is. j 4 -
Physical G yp fLj
A R
W 21.RE11tAItiLS
County Parcal ldmti6cationNo.(PIN)
5b.Latitude and longitude in degrea(mmutes/seconds or decimal degrees:
(ifwell Held,one latnong is sufficicot) 22.Certifieati
6.Islam)the well(s): 9\\-rmaxrent or OTemporary /L�L)o / Srgaaeve ofCemSedWell Contractor Due
/� ByNgningNbfomtlHnebycos6that 144 w 41)wm(wn)aomavicerdln aocoMmrewith
7.Is this a repair to an well: O
existing well: or ✓. O Isd)CAC 07C:0100 oe73A)CAC 02C.0200 Well Cptmsueolon SftWm*and rhat a wpy
ythif l,a repalr fill ob.Gnn'well cmamuellon ltJoramNon andarploln the an rung aJtM ajthG rerotdhar beenprorldrdbthe witowtar.
'rcpalr wrier EI!remm6 section or on Ute bock ofthfsfaser.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well conshuction info
construction,only l GW-1 is needed Indicate TOTAL NUMBER ofwells (add'See Ovee in Remarks Box).You may also attach additional pages ifnecesuny.
drilled:
9.Total well depth below land surface: 32-61 pL 24.SUBMITT AL INSTRUCTIONS
'
Foramll/ple well,list alldephe ydy/eredt(example-3Oo2200'0'ad2@100) (ft) Submit this GW-1 within 30 days ofwell completion per the following:
10.Static water level below top of casing. ( D (ft) 24a. For All wells: Original form to Division of Water Resources (DWR),
lfwuter level is above caring we•/+•j/�J Infofmahon Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. VI ! 0 .CIn,) 24b.For Injection Wells:Copy to DWI,Underground htjection Control(IUC)
��a at, — Program,1636 MSC,Raleigh,NC 27699-1636
CM Wall Merry,construction method: ' < -I 24e.For Water Su 1 and O en-Loo Geothermal Return Wells:Copy to the
(tar mgm,mmry,able.direct push,etc.)
county envuonmen heal depalhnent of We emmty where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water We1Is roducin over 100 000 GPD:Co lto D
PQImt Pro PY WR CCPCUA
13s.Yield(gpm)—L� Method of test 1 .1 11 MSC,Raleigh;NC 27699.1 1I It
13b.Disinfection type: ! 1)1 Amount:
Form GW-I North Carolina Deparanom ofl urimnmevyl Quality Division of WaterRaavicea
Rovued 6�aata