GW1-2023-01592_Well Construction - GW1_20230214

• II i
WELL CONSTRUCTION RECO _ GW-1 ForinternalUse
1.Well Contractor-Information:
II
L h -e 14.WATER ZONES
Well ConhaetorName FROM TO DESCRIPTION
�535 boo . �6 ft I
ft !NC Well 60traetor CerdficationNumber
IS.OUTER CASING for ma14-cased wells OR LINER(1f2P linble
FROM TO DMAMMER THICKNESS MATERIAL
Company Name
ft tt I.
' 16.IlVNER CASING ORTUBING eothermal elosed-loo
2.Well Construction Permit#: ( /C WL�la7�!J��/-�iZ FROM TO n*•*tea TSICIKNEss IMATERIAL
List aUapplicobk well eonrtrndion permfls(i a WC;Cororry,State Varlancc,ere.) ft 92- it -�,6L 1Z i
3.Well Use(checkwell use): ft ft I' in.
Water Supply Well: 7.SCREEN
❑A cultural FROM TO DIAMETER' SLOTSIZE TSICIKYESS MATERIAL
! ❑MunicipaWublle it ft in
❑Geothermal(Heating/Cooling Supply) idential Water Supply sin
uPP Y(single) n ft
❑radustrial/Commercial TMesideatialVater Supply(shared)
❑rrri do 18.GROUT
❑Wells>100 000 GPD FROM To MATERIAL EnmLAcn�NrMeraoD a<AMoI
Non-Water Supply W dL
❑Monitoring ❑Recove '
Injection Well: ry ft Yo el"a ti tA.
❑A uif It ft ft
q echarge ❑GroundwaterRemediation
❑Aquifer Storage and Recovery ❑S Barrier 19.SAND/GRAVEL PACK da licable
tY FROM TO MATERIAL EMPLACFIVIEKPMEIHOD
❑Aquifer Test ❑StormwaterDrainage L. . ft ft -
❑Experimental Technology ❑Subsidence Control ft ft
❑'Geotiiermal(Closed Loop) ❑Tracer 20.DRILLINGLOG attaeh2ddiflonalsbeetsifnecessa
❑Geothermal.(Heating/CoolingRetUm) ❑Other(explain under#21 Remarks) mom To ft I�DEseRntrtox eotor,earae sovractc Sir-etc.)
ft '�
4.Date Well(s)Completed: Z=/ - 2 3 Well M,# ft
,5a.Well Location: ft ft j
6 ZLt BLA n,0 aV-h•P,L) fa ft.
Facility/ erName Facility IM(if applicable) ft ft
Physical Address,City,and Zip ft ft
rS LL r{,1 21.REMARKSd 117iGir(?s G^1 t Tt?�:?DA:r�Tt t P e
Connry PareelIdentificadonNo. DWQi3'G'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll,field,one Moog is sufficient) 22.Certifiratioa:
.3 L�' 2L " S""N S ' 50 ' 37 " W � I
Z_ Z- t-3
.6.1s(are)the well(s): QPermaneut or ❑Temporary /`!♦'Z1 t Signaane RfCatiSedWell Contactor Date
� Bysigning thisfonn,Thereby certify that the wdl(r was(were)eotunucted in accordance with
7.Is this a repair to an existing well: [Yes or _IJNO ISANCAC 02C:0100 of ISli NCAC 02C.0200 Wdl Construction Standards and that a copy
Ifth/s is a repair,fill out darown welt construction iifornadon and explain the nature of the of this recordhar beenpravided to the well owner.
'repair under d21 remark section or an the bark of this fora. 1
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Qosed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW 1 is needed Indicate TOTAL NUMBER ofwells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMLTTAL INSTRUCTIONS
9.Total well depth below land surface:
For mul»plc wells list all depths ifd8errnt(example-3@200'and 2Q100) ( ) Submit this GW 1 within 30 days l f well completion per the following.
24a.-For All Wells: Original
' 10.Static water Ievel below top of casing: � 0 (ft) form to Division of Water Resources (DWR),'
#"water level is above casing,'use"+" ` Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. G! d ('m) 24b.For Iniectioa Wells:Copy Ito'DWR,Underground Injection Control(IUC)
Pro912m61636 MSC,Raleigh,NC 27699-1636
12-aug construction method: 24c.For Water SnnDly and Ouen-Loon Geothermal Return Wells Copy to Ore
(i a auge,rotary,cable,direct push eta) county environmental health departIItent of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d ge�For Water Wells uroducine over 100,000 GPD••Copy to DVVR,CCPCUA
13a.Yield(gpm) ,S Method of test: t Permrt Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount: ! G✓
'Form GW l North Ca IM X)epattment ofFavi .=t d Quality-Don of W.L Rcs.
urces Revised 6-6 2018