GW1--03117_Well Construction - GW1_20230428

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WET CONSTRUCTION RECO •(GW-1) For Internal Use Only:
1.Well Con., ' Information a
r." '14.WATER ZONES •
--
Well Contractoram FROM TO DESCRIPTION
5 '7 A •• 3-0 ft. i 6 d ft.
ft. tt.
NC Well Contractor Certification Number
W v `� ' U ' r IS.OUTER CASING(for multi-cased wells)OR LINER(fop liable). •
FROM I TO ft J
DIAMETER. I THICKNESS MATERIAL
CompanyName .
2 • 16.INNER CASING OR TUBING Geothermal closed-loop) •
2.Well Construction Permit#: ,� .J•7 a ci,S FROM TO DIAMETER THICKNESS 11ArEg ,
List all applicable well construction permits(I.e. WC,County,Slat;Yarionee eta) ÷Ift
in.
3.Well Use(check well use): it
•
• Water Supply Well: .17.SCREEN
• ❑A Cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ' '
gn '❑ ..'cipal/Public ft ft ._ in.
❑Geothermal(Heating/Cooling Supply) µ"..••:al Water Supply(single)
ft, ft. in.'
❑Industrial/Commercial CIidential Vyater Supply(shared) '
18.GROUT
❑Irrrgatio(i ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT &AMOUNT
Non-Water Supply Well: 23 a
• ,,•-„�, 0 ft ft
• ❑Monitoring z• ,1 . oT°, ft ft: Aject.
r'1 l 44/PI /V`t'
Injection Well: �r,
❑AquiferRecharge APR 2 b g. �`• ft.undwaterRemediation
❑Aquifer Storage and Recovery . DS Barrier • r 19.SAND/GRAVEL PACK MATE applicable) '• •
FROM TO
❑Aquifer Test inforvr:s ish Pr.'*c n MATES EMPTaoEMENTMETsoD
Drainage •• ft R
❑Experimental Technology ` ❑Subsidence Control ' ft ft
' ❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO ft • DESCRIPTION(color,hardness,soil/reek type,pin sire,etc.)
4.Date Well(s)Completed: 1"-2Y 2 3 wen ID# ft ft i bM a s .�o
La Well Location: ft. tft. O '"
. i it,t 3 LLc-- ft ft ;
• Factiity/OwnerName u''4 1
Facility RV(if applicable) ft ft. g.
S ram. — ,D 4 5 Gar,��ex- Rd ; -ft ft - /1./ 1-:
PhysitalAddress,City,and Zip ft.aM G 1YA/yI ,, ,21.REMARI{S/ _
•
County Parcel Identification No.(PIN) •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwelll—field,one lalloag is sufficient)• R
V' aq' 2 " 81 ' 1 2 S t 22.Ce �r� .
J/ N t W '/ C�
.6.Is(are)the well(s):.trmanent' or ❑Temporary E .O/ Signabue bf 6i �ctor :Z•s Z 3
y :. Data
200
7.Is this a repair to an existing well: ❑Yes or j o By signing this for,,.!hereby certrjythat the well(s)wor(were)constuctedIn accordance with
Ifthisisarepair,fill out known well construction information djd air the nature earth of t1SAhis record has been provided to thew ell OowneWell Construction Stmrdards and that a copy
'repair under#21 remarks section or on the back of this form. r.
•
23.Site diagram or additional well details:
• 8.For Geoprobe/DPT or Closed-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 of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMTITAL INSTRUCTIONS .
9.Total well depth below land surface: 1.16 (It)
Formuluple wells list all depths ifdj/7erent(erampk-3Q200'and 2(a)100) Submit this GW-1 within 30 days of well completion per the following:
2_b • (ft) 24a. For All Wells: Original'form to Division of Water Resources
filmier lend is above eosin&;case- i% Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 • (DWR),
),
30.Static water level below top of casing:
11.Borehole diameter: !!! (m,) 24b.For Injection Wells: to DWR,Underground�w� Program, MSC,Raleigh,NC 27699-1636 Infection Control(IUC)
12•Well construction method: l�(`f t 31L r ,►r
(i.e.auger;rotary,cable,direct push,eta) 24c For Water Supply and Open-Loon Geothermal Return Wells:Copy to the.county envuonmental health department of the county where installed
• FOR WATER SUPPLY WELLS ONLY: -
e 24d.For Water Wells product:a over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield.(gpm) -) C Method of test , ,Raleigh,NC 27699-1611
type:
1 / ' t auk:
u • Penult Program 1611 MSC if
13b.Disinfection 11''� Amount ',
From GW-1 North Camrme :....