GW1--03413_Well Construction - GW1_20230515

WELL CONSTRUCTION RECO GW-1
�.) For use Only. ;
L Well Con ormati j
10
14 WATERZONES
well Co rN TO .
�'Con.paqylhme
WCUrintiaetorCrsdfia6
er
15 OUTERCASIIVG formulti-nsednells ORLIIYER Ifa linble
FROM TO DrdMLTER TffiC auss MATE U L
2 ft ft in.
2.Well Coastrnction PerrolM J 1 I. 5 16 1NNE1Z C'�S1NG ORT[JBIIVG tLermai doeed-10901
FROM TO DIAMEr1tiR TOCrQGss MATEIWL
hiss all applicable well eonstrudlonpernrrts(te.inG Carmy,Sim.;Yar/mrea ft s?9 ,
3.Well Use(checkwell use): fr
ft is
Water Supply Well:. 7.SCREEN
bAgricultural FROM TO arAMYiER SLOTSECE TmCrOm?ss MATERrAL OMtmicipaUPublic ft ft
D Geothermal(Heating/Cooling Supply) 1=UWtrSyPIy(sigle,)OIndustrial/Commercial fttial'Water Supply(shared) is.GRot7T :
0krigationOWells>100 000 GPD FROM To MA aA
EMeLACEatErrrMeraoD dMoONr
Non-Water Supply Well: ft ft:
OMonitoring ORecovery 3 i t
lojection WelkIL
-
OAqurferRechne ❑GroundwaterRemediation ft ft
Wrr&61;
OAquifer Storage and Recovery OSalkikyBfla •. 19•SA1VD/GItTO I
OAquiferTest OStonawatefDtaimage da linble
FROM TO MATERrAL E XACEM METHOD' ft R
OFatperimentalTeclmology OSubsidence Control ft;
OGeothemial(Closed Loop) OTracer •• 20.DRII.LINGLOG atlacb additional sheets ifneeess
OGeother W(Hea&9/CooliugRetum) OOther( lairunder#21Remadm) noM TO DESCttIpirON color.hardam,mafne><fte. aL
ft ft.
4.Date Wells)Completed: —9-213
wen ID# ft IL
Sa.Well Location: ft ft
C Ml 1'Gt, T h h P,i ft ft
Fa ' /Orro N—=C
Faw7rtYID#(rfapptipble) ft ft
PLysral Address,(Stl:and •ft f "d..+ A► �j6 -
tnn 2LREbYARKSlrt O
Coonty ParwlMnOationNo.
5b.Latitude and longitude in degreestminutes/seconds or decimal degrees:(ifwell field,oak]aNiong'is s� � u
27.
0 y N �
.6.Is(are)the wells: e ' L-3
() i t rmanent or OTemporary siEana� f Cow D�
7.Is this a repair toaneristingwell: Oyes or &e.
83'j►8etngth ofm,IherebYcal dt/rithcveU(s)war(wcm)conrwwcdinaccor&wmwizh
J th/sisar a IS.l NCtC 03C.0I00 arTfAAVAC 03C.0200 WUf Cpnm cdon Swndards and that a copy
f apair fill ow weu cenzvudlon hrformation tha name ofthe aldeu reeordhas beatprveNded to the well owner.repalrrmder ill{onardsrecCon oron the baekofb*form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Qosea Loop Geothermal Wells having the same You may use the back of tbb page to provide additional well construction info
construction,only 1 GW-1 is needed Indicate TOTAL NUMBER
ed ofwels (add'See Over in Remarks Box).You may also attach additional Pages
sifnecessary,drill
�/(( MITTAL
9.Total well depth below land surface: 166 ,
VD ' 24.SUB R STRUCTIONS
(ft) ,
Forarrrliple wells lies a/!depths Ifdi�ereni(rsmnple-3(o)200'mtd2pa 100) - Submit this GW-1 within 30 days of well completion per the following:
30.Static water level below top ofcasing. tJ (ft) 24a.For All Wells: Original form'to Division of Water Resources (DWR),
7fwatertevd is above eosin&ure InfonmationProcessing UWi 1617 MSC,Raleigh,NC 27699-1617
1L Borehole diameter. O {m.) 24b.For Infection Wells:Copy to DWG Und
amund Prosmn,1636 MSQ PUL109b,NC 27699-1636 Injection Conhol(lUC)
12.Well construction method:
C«auget;rotary,able,dhVdPrrsl4 et-) 24c.For Water Summly and Ouen--Loon Geothermal Return Welly Co to the
county envuonmental health department.of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells rodncin over 100 000 GPD:Copy to DWR Cq, A
13a.Yield(gpm) I Method of test: Permit MSC,Italergh,NC 27699-1 11
tr
13b.Disinfection type: E
Amonut: -
Fob GW,-1 Ninth Cmmre.