GW1--03699_Well Construction - GW1_20230530

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WELL C I`STRUCTION CO (GW--1) • For Internal Use Only:
• 1.Weu Con. . n; .
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Well Contactor 'acne
' • •14.WATERZONES . f•
FROM TO DESCRIPTION
• • 5 -7 -A • o� 42t
NC Well euntraeter N ft.
TLUA)TY1 15.ODTER CASING(for multi-casedwells)OR LINER(ifap limbic)
CompaayName a.le ' ! '��`•' FROM I Toft. I DIAMETER. I TEUCECNESS MATERIAL
(� 16.INNER CASING OR
2.Well Construction Permit#: ` l(A ^tj • FROM TO TUBING(TeothermaTEXCed-laop)
List ail applicable well constr ction permits(Le.mG 4 K DIAMETTR' T .C li MATERIAL
�,:star Variance.ett:� �- 1 � �,�f- f� .��/� '°• �l C ti F Yt�3.Well Use(check well case): '• ft •
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ft is •
'Water Supply Well: • .V.SCREEN
. griu(yuyl OMtmicipal/Public .FROM TO DLIMEIER SLOT SIZE THICKNESS MATERIAL
ft. in.
Geothermal(Heating/Cooling Supply) CResidential Water Supply(single) ' -
Oladustrial/Commeccial .
OResidendal Water Supply(shaved) 1a.GROIIT • .
OIvrigatiotl OWells>100,000 GPD , FROM • TO MATERIAL EMPLACEMENT &AMOUNT
Non-Water Supply Well: - 0 ft ?? ft
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• OMonitoring • OReccvery - rf.1 An, d
• Injection Well:
OAquiferRtxhavge r�l o►A' rQ�v�„ C
OGvotmdwatetRemediatioII ft I
OAquifer Storage and Rtxavery OSalmityBariier '. 19.SAND/GRA'VELPACK of applicable)* . •
FROM TO •OAquiferTest • OSto Dra�ge • ' ft 8 MATERIAL .e�>Isrrb�IaoD
OExperimentalTechnology OSubsidence Control ft ft.
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• DGeothemnal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets ifnecessary)
OGeotheImal(Heating/CooTmgRehm* ❑Other(explain under#21Remadcs) PROM TO' • DESCRIPLION(mbr,hatdaea,za0/nsktrpy siim,ue)
ft ft •
4.Date Well(s)Completed:5-2 Z-Z Well ID# • ft 'ft •
5a.Well ft.it ft j } .
Coal)._
. 1:----..d,,,,,-,t 2,., ill) • •
• Facility/OwnerName Faciility1D#(ifapplieable) ft' r
'
.r)41-
I S L;h n,.�; MI l Rd ' �. ft �v . '< ,. ,... .
P • !+rdl �. zap ft. ' ft . PviAl Z[�z3
• l l 1 b. 21.REIVIAR&S! -
• CO PareolIdentifimtionNa(PII� •
Mod.it,. :..,, i . ..
....•.-._:3;ti,i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one 1at/longis sufficient)
22.C: • o
>lai 3 ' ! j N S / - .1 1 3 .W •
2/ , 5.2 Z _z
.6.Is(are)the weII(s): permanent or OTemporary f 730 / Signature df el Contractor •
Date 3
7.IsthisarepairtoaneristimgwelL• OYes or * �•drind&sfoil,7herebycatth*thatthe ells)wariwere)eorapvetedinaeunn'aieewlth
"fats Irar 0 ISth co 02C.0I00 or35.!`NC,fC Owlll m O.WdI COmrur+cBon Stardardr and that a copy
• main fill ontlnown well construction firfwmatlon and lain the nature°jibe cfthis recerdhas benVcavlded ie thecae l awn=
repair:older i21 rrmarlarection or on the back ofthisfonn. • .
23.Site diagrim 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 ifnecessavy.
drilled:
� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land•surfacea U/ (It)
FormulOpie will:list all depth:'dif'different(example-3g4200' ()(00) . Submit this GW 1 within 30 days of well completion per the following:•
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1 g.
10.Static water level below top of casing, µ Q („) 24a:For All Wens: Origin form to Division of Water Resources (DWR),'
lfwarerlevellsaboveeculn&;acre+/�`l infomlationPmeessing Unit,1617MSC,Raleigh,NC27699-1617 •
11.Borehole diameter. t I1 a • -{m•) • 24b.For Injection Wells:Coi4tO
Ng
D6994 Underground Injection Control(NC)
12.Weft construction method: R( w•I-• ./rev' °��•1636 MSC,Raleigh,NC 2799=1636
(Le urge{rotary cable,di:eetpusb,etc.) 24c.For Water Snmply and Ooa n=Loon Geothermal Return Wells:Copy to the
county,envkonmntal health de •
edepartment of the county where Installed
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• • FOR WATER SUPPLY WELLS ONLY:. •
ii /; 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) I Method of test: (IAA."+ Pent Program.1611-MSC,Raleigh,NC 276994611
Is
13b.Disinfection type: 7 •
l Amount: ! . 6
Form GW-I North C mTn.T%:....a......-a e ....., .. -.--