GW1-2023-01772_Well Construction - GW1_20230223

WELL CONSTRUCTION RECORD(GW-1) For Intefaal Use Only.
1.Weld Ecautrac toy Information: 00 5
14.WATER ZONES I {
WelICosuaclerName FROM TO DFSCRIP170N
s' fL fb , �
NC W ITICC'ortta C rtiHcaHoa Number t IS.OUTER CASING for mnl tared we11s.OR LINER o Itcable
FROM TO DIAMEM Tmq=s MOMM
I, �. fit. lm lid' (i CompanyNamc
// J •26.1NNER ING OR TUBING eotbermal closed4coul
2.Well Construction. FROM TO DIAIEUM 7MCKNESS I MATEWAL
List all appl—ble-11 construction permits(it:UIG Cantry.State.Varlanee,eta) it. fL le.
3.Well Use(check well use): ft. IL In
Water supply Well: 17.SCREEN
FROM TO DIATA SIMSM THI S MATERIAL
OAgriculhual OMumicipaUPablic rL 7tL 'ail°'
043cothermal(Hcating/Cooling Supply) 'residential Water Supply(Single) tL fL V 7v
171ndustriaUCommereial ❑Residential Water Supply(shared) 18.GROUT
Ohri ation OWclls>100,000 GPD FROM TO MATERML EME!AtT•a'"OD a ADr uNr
-
-Ilion�terSu`PP YY Wdf: -
OMonitoring ORecovery IL IL I;
Injection Well:
usfer Ruch ft. R
13A q ' urge OGmuadtrrsterRemediation
19.SAND/GRAVEL PACK' o Dcable
OAquIfer Storage and Rceovery OSalinityHarria FROM TO a TEML E6rPIACEIIII•2rPHi=010
OAquiferTest OStormwaterDrainage R• tt 2
13Experimental Technology OSubsidence Central R 11
OGmtheimal(Closed Loop) OTlaeer 20.DRILLING LOG attach additional sheets If neres
❑Geothemsal(Heating/Cooling Refum) OOther(explain under#21 Remarks)] FROM To DESCRIPTION color bade spWrock cta
4.Data Wells)Completed: Well IDk ' _L
52 Well Lo 8one tL
nq
GFscwty107EPmd Facility IDO(if appHcabie) R
jjak �
Physical Address.City,A INP R- IL
C b Sa SEA 21.REMARKS 4
tm y Parcel MentificationNo.(PIN)
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees:
orwall field,one Iat/long is sufficient) r
x 2 �C� ;2 // W 22. ertIticaHaa•
([f t7
6.Is(are)the well(s):�t1�Eermanent or OTemporary Si ofCrnIHed CR
o ;
s gthvf tl d Acwell(s)was(ivem)construetedbraccordmiaewith
7.Is this a repair to an casting well: OYes or i•10 A NGtC 02 0 or 1SAC 02C.0200 Krell Construuion Standards and that a copy•
Ifthis it a repair,fu7aut!Drown tirell construction information and taplaln tha nalttne of(lie ojlhis newrdlrar been provided to the well ownerMOR
repair under#21 remarks section or on the back of thisform.
23.Site diagram or additional well details:
8.For Geoprabe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction iitfd'
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: `/ (fL)
For multiple wells list all depWs ird�erent(sample-3Qa Z00'and 2QI00) Submit this GW-1 within 30 days of well completion per the following:
10.Stade water level below top of casing:, w�w (iL) 24a. For All Wells: Original,form to Division of-Water Resources (DWR),
Information Processin Uni 1617 MSC Rader NC 27699-1617
IJtinlo level U above cariirg,use"+" - S t. .�• --.. . . .---,- •
NI
31.136rehole diameter: r/ (in) Z4b.For Infection Wells:.Copy to DWR.Underground Injection Control(lUC)
/. Pmgmm,1636 MSC,Raleigb;NC27699-1636
12.Well construction method: -- I' -
t e.au er m able direct 24c.For Water Su 1 and Cl en-L'oo Geothermal Return Wells:Copy to the;
C,_ 8 m*Y,, Pam.« ) county environment - eal deparion iofthecountywhercinstalled - --•-
FOR WATER SUPPLY WELLS 24d.For Water Wells ipraduclaz over,100 000 GPD:Copy to DWR,CCFCUA
13a.Yield(gpm) Method of test: i'i Permit Progratn,1611 MSC,Ra ei?A NC 27699-1 11
13L Disinfection type' Amount: d "7
Form OW-1 Notth Camlim Department of Environmental(j Slity-Division of Water Resources Revised 6.6-2018