GW1-2023-02820_Well Construction - GW1_20230420

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WELT,CONSTRUCTION RECO ,(GW 11 For Internal Use Only. '• •
I•' 1•Well Contractor. rmatio .
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A?. •1t WATER ZONES
Well Co rName FROM TO DESCRIPTION --
r5 3 5 • MDR.'
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NC Well ContradorCertificationNX
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15.OU ER CASING(for multi-used nrells)OR LINER(ifap finable)�jV -� PROM f TO DIdMSrFdt THICKNESS MATERIAL
CtimpanyName i< J in. I
2.Well Construction Permit#: o I." 16.INNER CASING OR TUBING(geothermal eh:fed-loop) •
FROM TO DIAMETER THICKNESS MATER=
List all applicable well etuutratolonpennitr(Le.WC Cororry,Slalq Vailaneq etc) 4-1 !t. OO Z ft: -57/lj ilrw P n-'
3.Well Use(checicweII use): ft in.
Water Supply Well: •
•SCREEN
• OAgricteltural OMunicipa1/Public FROM TO DIAMETER SLOTStzE THICKNESS MATERIAL
• ft ft. in.
ElGeothermal(Heating/Cooling Supply) residential Water Supply'(single) ft R in..
OTndtutriallCommercial . CResidrAtial Water Supply(shared) itt.GROUT •
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• Oirrigatiop [Wells>100,000 GPD . FROM TO MATERIAL EMrr CEMENEMErsOD&AMOTIN?
Nun-WaternpplyWell: • a ny D 7 3 ft pe .A/(
• OMonitorin < <p
• Injection well: fc �l A p(1�p-
• ' CAquiferRecharge OGmtmdwaterRemediation •
• ft.
OAquifer Storage and Recovesy OSalinity Barrier' ., U.SAND/GRAVEL PACKCdaPplieable) •
FROM TO MATERIAL EMPLACEMENTMEIHOD
OAquiferTest OStormwaterDraiiage• I • ft. ft.
DExperimental Technology OSubsidt nce Control ' •ft • ft
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• OGeothennal(Closed Loop) • OTracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeoth• al(Heating/CoolingReturn) OOther(explain under#21Remars) PROM ft. TO • DESCRD?TIoN(mler.6anduev.soiunekype,etsmsee•d�)
ft.
4.Date Well(s)Completed: 3.4 Y 43 Well ID# ft •
Sa.Well Location: ft. • ft. v. d Sr rrvt)
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•M1el-faeI Kerold^l • • ft . ft. 1 D l-- ss121 • -• Fa / Name FaalityID#('rfappfieable) ft.
abs Rd Any doG -( •�• •. • •. .�•�
Physical Addres City,and Tap •
(A) 'All Le. J 2LR$MARfsf' n P R 2023 _
Co ParcelIdentifiationNo.(P/N) �
IO's% a {; •! . „i n 7 t_,Ci a
Sb.Latitude and longitude in degreesfminutes/seconds or decimal degrees: ''°s°�� -'L'
(*Ewell field,one Ltllongis sufficient)
3 r r � �/ l._ 22.Certification:
b I i . N 7 .` W ..i1,31; & J"'
.6.Is(are)the well(s): Crmanent• or OTemporary /3 G v S' en cotraetor Date
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7.Is a repair to an misting BYsf fling thirforr,!hereby certify that the well(r)war(were)eonnlumedln aceordm:uwlth
l I s t this g well: OYes or No ISANCAC 02C:0.100 or752I NGIC 02C.0200 Well
j repair,fill out 1»own well consnuetion&formation d rah:the magi of the ofthir record harbeat Construction Standards and that a copy
'repoirundeill21ranark reetlonOran the back(fthirform. provfdedtoOiewellowns:
23.Site d*agram.or additional weII detans:
• 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells hayiDgthe 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 Ova'inReMarks Box).You may also attach additional pages ifnecessary.
dulled: 24.^^
9.Tofal well depth below land surface: I� MT1T�� UCTIONS • '
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For war lint all depths ifdlfjerent(example- and.4. • Submit this GW-1 within 30 days of well completion per the following:
10.Static water Level below top of casing: 6 D • ( ) 24a. oar A W� Original form to Division of Water Resources )
Ifwaterlevelirabovecnrin�ive�+1/' g nit,1617MSC,Ralei � 'Raleigh,NC 27699-1617 •
1L Borehole diameter: {m.) 24b.For Injection Wells:Co
,�1 a . Pro N to 99 1 Undergtnimd 7ajectioa Control
12•Well construction method: ' \pi _ ��y� 8�'1636 MSC►Raleigh,NC 27699-1636 ��
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(iiaauge{tinny.cable.dtceetpust4da) • 24e.For Water Sn 1 and en:Loo Geotbermal Return Wells:Co
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• FOR WATER SUPPLY WELLS ONLY: •
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COunty environmental health department artist county where installed PY to the
ter For water Wells nrodna ei over 100 000 GPD Copy to DWR,CCPCUA
13a.Yield(gpm) ' �� Method of test ��a �- . P�r�gram.1611 MSC,RaIi Raleigh.•
13b.Disutfection e: ' 1 - i i
`B I Amount: .
7) iH
Foy.GW-1
North Carolina Deeatewee nvs• -.,.._..-• ..... --