GW1-2023-02722_Well Construction - GW1_20230411

WELL CON§MMTIO RECORD GW 1 For Intemel Use Only:
1.Well Covtractur Information:
1 MWATERNE
DESCIUFUIJ
NeU CorinacwrNaare S
s��L AfL
NC Well Coatraetor Ce:fd:eation Number ma1H<ased tveUs OR LINER aUehlpuyn�fl FAo,� 43"� urAtr�-rf 1& THI 0 �P r.
CarapaayNsme 16.INNEERV: G OR TUBIN . othcrtaat closed=Ica
-FROM 1'O D7AMErER TffiCIaVi�SS MATEttW.
2.weuConsirncttonPermit#:_ �lS���"/DO7OO m
Un aU WUwbra tgeft eonrWel7on permfLr(Le.WC Cmu+4.Slate.Varf--,eta.)
IL !4
3.Well Use(checkwell use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOrsr� affic�iRss MATt;RIAL
❑Agricultural .❑MlmicipaMblic Li'5'1t: 7 5*n A1 . 4 tr C
UGeothamal(Veating/Cooliag Supply) ,Q t6ldcatial Water Supply(single) IL ft. bL
;C1lndustriwCo�eroial ❑Residential Water Supply(shared) l&GROUT
.❑Wells>I00 000 GPD FRO TO MATEIOAL EMPLACFMENr 4lErHOD&AMottxr
❑Itri 'oa ! IL /�Q R. IIGT QV
'Non-WaterSupplyWOU. _ _
ft.: .13mohitoring ; ❑Reco ft.
InjecSon Well:'!' ffi R
DAQuif�iltecltai$a , - ❑CrroundwatcT R—aRtion 19.Sp1dDlGRAVEL PACK f a Ueahle
❑Agatfer.Stoiag"iiandRecovely ❑SalioityBarrier FRO:a TO arAYlntrAb Fati'racer, vrrt>rtroD
❑"iferTest ❑StortnwatarDrainage a0 7 0(3
DExperimental�echao]ogy ❑Subsidence Control n'
pGeolheinral(Glosed'Loop) ❑Tracer 30rDRlLLiNGLOG attachadditioaeieheetslfa
FAObr TO DES ON color Leda ralihoelt rAs
[]Geotbermal(II • CooiiagRetam) ❑Other iainunder#211temad, / tt VL SeM -C ei
LF
I ' ' q
4.Dote-•- eR(S)•0ompleted: ` �` •A.Well ID#_ n' !L
FL rL
LOT
•5a WeD•I:ocatlpn• � .�
i' . . faciGty%0lvnerNaila`e r FacUiwMH(3fappUeable) r a
r V^ 1 W�1Sl1i�$Tdh m
_ j q nc tL is APR 11 Physical Address.City,and Zip +•► Q -
n�T� ' 2 / "f . 21.REhrARKS
Q , Passeirdentitieacon No.(PIN)
5,.0.Latitudeand longitude-inAegeeWminutWseconds or decimal degrees:
(TWO
6;lld;oae•�et/lougissi�aient) 22.Ce caftan• g
It
Contractor. -Is(am).thewell(s):�rmaneiit or ❑Temporary
Sigaatura of Cerilped Well Contractor Date
f Bystgnlagthlsjorm.I he+eby cent/that the wdl(s)was(w—)constrrrctedln aceordaace wit"
7,.)q this a reptiir ba tun exlsting.weD: ❑Yes or ago13ANCAC 0IC.0100 or 15d NGlC 02C.0200 Well Canc"aun Standards and that a cope
IjthtrO a repatr.Jil7 oat brmvrr x�e1!�m ecrirquetJon tt�ormatlon and erp"rin the nature ojSte ojthis record has beery pmvided to the welt owner.
repair,uader#dl'-+ arra seaon or on•the backojthl3 jornt. 23,Site dlagram or additional weH detalls:
&YturGeoprby plpPT`or•Clo'scd-)(:o op Geothermal Wells havingthe You may use the back of this page to provide additional well construction info
same
(add'See Ovee in Remarks Box).You may also attach additional pages ifnecassgry
iG .
conshtYotioq:otilyl:GVICl -ieedi& indicate .
drilled• �' 24.SUBMPITAL i1VSTRUCTIONS
9.Tgtal tiveU A li'-belgw land surface: `� (R') Submit thle GW-1 wlthln 30 days of well completion per the following:
F.or 4 dRpte'tit+e flIg-'•alydepths{fdt8etaznt(example-3Q20U'and 2®1001.
( ) 24a. For All Wells: Original form to Division o Waier1R. 0=es (1)WR),
10.Static water ,I617 .
;V.el'below top of easing: Information Processing Uni%, 617 MSC,Ralelgh,
Ijiaater level it a�iove easirr$use 1..
24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole d ameter: ��^ (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well•cops ction method:_ hfl V� b� 24c.For Water Supply and O en Lbo Geothermrl Return Wells:Copyto the
(Le.auger.tatazi'cable,direct push,eta) county en trmeatal h th epattment o a cotnitywhetE ins
talled
FOR WA E41SUPPLY WELLS ONLY: Z4d.For Water WeIIs rndircin over 100 0U0 GPI):Copy to DWR CCPCUA
,,//�� Permit Program,I611 M COM C 27699-1 11
13i%YUld(gpm) Method ofte-*. Alf i
i
> 13b.Dlslnfectiou type: C Amountt, 3 OZ
Form OW-1 North Carolina Department of Etnrimameaud Quality-Division of WeserResourees Revised f 6 z018