GW1-2023-02391_Well Construction - GW1_20230404

LC TS Y N RECO ^ GW 1
�) ForintemalUse Only:
L W99 ContractorInformation:
wc11 Co ,=. 14.WATER ZONES
FROM TO DESCRII7ION
NC Wen Coanaetor Catificadoa Nbmbar ra fL
16.0 CASING ror multi ersed tivelJs OR LAYER�f a Geable
DIAT?�rER Tffi �TII
CompanyName �P-e�wq
ft. VAL
2.Well ConstructionPern it#: � W 16.11MR CASIlVG OltT08ING thermal closedloo
Las!all app&wbk weft eonrtruetl FROM TODAtER1AL
wuy,State;Ymiancq ft 5 fa S�l is ft.n tl z
3.Well Use(checkwell use):
R in.
Water SupplY Well: 7.SCREEN
❑Agricultural ❑ cipal/Public FROM To DraM SLOTSIZS 21IICIINFSS MATE1tLtL
❑Geothermal(Heating/Ccoling supply) fa R _ in
uPP Y) 'dential Water Supply(single)
❑Iadustrial/Commercial []Residential pirater Supply R & rn
❑Irri o n (shared) 18.GROUT
❑Wells>100 000 GPD FROM 7
To Non-Water Supply We1L rMPLACFMENC?dXMOD&AMOtWr
❑Monitoring ?j fa
overy❑Rec •� -1
' Injection Well: ft fa R
uifer Y
❑A q ft �` !
echarg° ❑Gmundwatergemediation ft
❑Aquifer Storage and Recovery ❑SalinityBanier . I9.SAND/GRAVEI,PACK,fa liable
❑Aquifer Test TO MAT�re ��C 1rME18oD❑StormwaterDtaiaage ' ]MOM ft & i.
❑Experime�al Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(HeatinCoolie g/ g 20.DRII,LINIGLOG attach additionalsbeetsifae eess Return) 130ther(Wiainunder#21Remarle;) FROM To DESCitIPT10N eolor.bardcea•soiuroek
� ft ' sin.eta.
4.Date Wents).Completed• 3-2-3-2_3 WenM#
5a.WellLocation: m -
rc
• Fae�lsty/OwnedName • • 1 /� n/� .
Fa-W]D#(ifapplieable) & ft
1 i C�-a h-r A.v — 2 U,
Pbys LA
IJ. ddtess,Gty ao)dTap R -
v V�t�C.t IJL�� 2L RENARK3(,
I-Ounw' Parcel Idaatifieatio NNo.(PIt� '
5b.Latitude and longitude in degrees/minutwlseconds or decimal degrees:(ifwellfield,onelaNiongissnfficieat) ;
22.Ce" ration:
W
.6.Is(are)thewell(s): f rmanent or ❑Temporary r 1 06 f i Rr� ntraetor ��2-3
` Date
7.ls this a repair toan existing well: ❑Yes or NO ByrtB++lagthisform,lherebyceiyifythatrhewett(s)xar(Sverc)eansauuedlnaceordmrcew!!h '
Tjthts isarepair,felt orakrroxm weft eottrlraellon i otmatlon 15ANC-IC 02C:0100 orM NCAC 02C.0200;Ydll Cpratraenon Staadottir and that a copy
^j ezplobr Ore natrae ofthe oflldrr—dhas beenprawded to thewell osmer
repairrender#2I tonarlsrca_lon oron the baaofrhfsfomc
23.Site diagrim or additional well details:
8.For Geoprobe/DPT or Closed--Loop Geothermal Wells haviogthe same You may use the back of this page to provide additional well construction info
construction,only lGWlisneeded 7adic
dulle ateTOTALHEMMERofwells (add'SeeOveeiaRemaft]36x).Youmayalso attach additional pages ifnecessary•
d:
ID • 24.SIIBmn7AL INSTRUCTIONS '9.Total well depth below land surface: '
FormrrtuWewe&&t all depenf4-erern k-3p2001aad2©100� (ft) Submit this GW_l within 30daysofweII completion per the following.
10.Static water Ievel below top of casing: ( ) 241. For All Wells: Original fora to Division of Water Resources (DWR) '
It Bo ho is above ter:Cadi ia' 1i InformationProcessingUnit,1617MSC,Raleigh,NC27699-1617
1L Borehole diameter. U' �
(m.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
12.We1t construction method- 0 -a w �8 ,1636 MSC,Raleigh,NC 27699-1636
. (Le.auge>;rotary,eablq direetp,;�ere.) 24n For Water SnnDIvand Ooen-Loon Geothermal Return We11r Copy to the
EYIeld
u rrj Y WELTS ONLY: cowry eavu°nmental health department of the county where installed
24d.For Water Wells prodnane'over I00 000 GPD Copy to DWR,CCPCUA
O0 Method of test: ermrtYro
w gram,1631 MSC,Raleigh,NC27699-1611
type: 7D l
Amount:
Font OW-1 North CaroliaaD
eP»tofEw&on mental quality-Division ofwatcrReamacer'
Revitcd 6--2018

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