GW1--04336_Well Construction - GW1_20230707

WELL CONSTRUCTION RECO (GW 11 • For Internal Us•e Only: � •, •
• is Well c retractor. slag
Wen Co rName CATER TO NFS DESCRIPTION
-
3 , 5 • �7,00�'I�5V h
NC Well Contactor Certification umber
I
.� ,h�` . / A O I5 OUTER CASING(far multi-'eased yells)OR LINER 8fap liable)
( I J,�f! ~"' FROM TO Dlt rPR THICKNESSMA2ERLIL
Company Name I ft I us.DIAMETER..
2.Well Construction Permit#: A/ 16 INNER CASING OR TUBING(geothermal doted loop) •
FROM TO DIAMETER THICKNESS MATERIAL.List all applicable well construction permits UIC,Corouy,Slate;Yaicatce act) �••/ 3/ft fe•
E7 Cig m' 7 A/C
w � .// y � .
3.Well Use(check well nse): ft in-
Water Supply Well: 47 SCREEN
cultural FROM TO DUMMER SLOTS= TRIMNESSMATERIAL 011unicipal/Public ft ft •_ m,
eothennal(Heating/Cooling Supply) OResidential Water Supply(single) '
Olndustrial/Commercial O 7D•'
OResidential Wafer Supply(shared) 18.GRo17T
°Irrigation °Wells>100,000 GPD • FROM - TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: - J
• °Monitoring • _ °Recoveryft !�Ck Y Aft i�!.-r
• Injection Well: ftPdrtf-a.; A
OAquiferRecharge iati
OGroundwaterRemedon !
OAquifer Storage and Recovery OS yBarrier •. 19.SAND/GRAVELPACIC(iifapplicable) •
FROM TO MATERIAL EMPIdcranaITMernon• OAquiferTest OStormwaterDrainage . r . ft ft. _
OF.xperimentalTecbnology °Subsidence Control •
• .OGeothemlal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
°Geothermal(Heating/CoolingReturn) .°Other(explainunder#21Remarks) PROM TO DESCRIP ION(color•bardoea,soiVnek true.tram sac,ere)
ft.
4.Date Well(s)Completed: (4 Y'23 Well DM • ft •ft;
a-yrh Ai..?
52.Well Location: g
at C ss4•eV P I
• Facility/ Name .. Faglity 1D#("fapplieable)
ehrtrr iq CA ti, at fd - MGICnt6'ttom'Rd• ':•ft ft. f$
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Physical Address,thy.andrip • ✓ ft. j ft .'/i% 4� f.'6P'a
40 cf t(,l ry • • ,2LREMARKS/ - Zili,. 2 a '
Co Pa"eol Identification No. 017l�Re' nc�
(PIN)• s�n .
5b.Latitude and longitude in degrees/minutes/seconds.or decimal degrees: '
("dwell field,one lat/longis sufficient) j :ar c'$i 1.4,. _
•
3t. !L ' ) N /�(/ , �p ' 3 22.Certification:
f W 6-2 7J
.6.Is(are)the wells): t3 etmanent or bTem o Sigaanne•Cuutifidd-Well �,
71 P rY ��O/J Contactor Date3
By tbirfoim,!hereby caelb that thewell(r)war Ogre)eoirpveted to aceordeneewlth
7.Is this a repair to an existing well: °Yes or No ISd NCSC 02C_0I00 orr7S,!NCSC 02C.0200 Well Censtraetlon h enl rdr and that a copy
IjthIsirarelair;dill old brown well con n Jio tit tonnatIon an ceplain the noiwve of the•. ofdgi record has bee»pmvldcehe thewei essun.
•copal•render S2l remarb•reet on oron the back ofthisfonn.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or.Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1GW1isneeded. Indicate TOTAL NUMBERofwels (add'See Ovet in RiTiarks Box).You may also attach additional pages ifnecessaxy.
dulled:
`� 24.SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: �J (ft)
Formu/tiph:wear hit all depths 1dlerent(ceamplc-3Q200'and 2®100') Submit this GW 1 within 30 days of well completion per the following:• •
10.Static water level below top of easing: /O a • .(1t) 24a:Poi:All Wells: Original form to Division of Water Resources (DWR) '
Ifwater•kvd is above eating:we+- InformationPmeessingUni1;1617 MSC,Raleigh,NC 27699-1617 • '
1L Borehole diameter. 1j�l
• {m.) 24b.For Injection Wens:Copy to DWR,Underground Injection Control(IUC)
12.Welk construction method: /S t)fa 17_ /1W >'�$ram,1636 MSC,Raleigh,NC 27699-1636
(ter auger,rotary,cable,di"utpasb,etc.) 24c For water Supply and Open-Loop Geothermal Return Wells:Copy to the
•
county environmental health department of the county when installed FOR WATER SUPPLY WELLS ONLY:
n //�� 24d.For Water Wells Prod.ncinkover100,000.GPD:Copy to DWR,CCPCUA
132.Yield(gpm) I) • Method of test (IA., ' Pen utProgram,1611 MSC,Raleigh,NC 27699-1611
is
13b.Disinfection;type: ` 14- At: Ji v/mounr
•
Form OW-1