GW1--04365_Well Construction - GW1_20230707

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WELL CONSTRUCTION RECO (GW-1) • For Internal Use Only. • , . •
• 1.f Wel1 C ;.tor-Information: •
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14.WATER ZONES
' Well •••• 'N FROM TO DESCRPTTON
j- �' 7,n • • /oo ' .3ou ft '
NC Well Contractor Cettifieationxumbei
ft ft.
• is.OUTER CASING(for multi-cued wells)OR LINER(if ap limbic) •
a e /p s J- Q„l . FROM TO DIAMETER THICKNESS 1 MATERIAL
CompanyName (3)..0'fil^'vt vv' — ft. ht.
I �j 16 INNER CASING OR TUBING(geothermal clad-loon) •
n J
2.Well Construction Permit#: 1 ( .2 k0 FROM TO DIAMETER THICKNESS _ MATERIAL
List all applicable well contraction perms s(Le.WC Cowry,State,Variance,etc.) • .-•(..I ft 58' ft $lie m• I,!C i. a .
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K�
3.Well Use(check well use): ft ft m /
Water Supply Well: • .47.SCREEN
OA cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL •
'DMunicipal/Public f ft in.
E Geothermal(Heating/Cooling Supply) sii•'dential Water Supply(single)
ft. ft. in;
0 0lndustriaJCommercial Benda-Water Supply(shared) •
O]iri ho 18.GROUT
n l7Wells>100,000 GPD FROM TO • MATERIAL EMPLACE ENTMEIBOD&AMOUNT
( Non-Water Supply Well: ft ft
" : OMonitoring • ORecovery ft_
ft.
Injection Well:
OA urferRe a !t .ft .
q eharg OGroundwaterRemediation
•
OAquifer Storage and Recovery . OS 19.S�/GRAVEL PACK Cif applicable) • •
alinityBarrier •. FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑StonnwaterDrainage ' . ft ft. .
DExperimental Technology DSubsidence Control fc ft
• OGeothetmal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) FROM TO • DESCRIPTION(color.hardness.sea/reek types resin size.etc.)
ft. ft .
4.Date Well(s)Completed: G —/G-23 Well ID# ft It
Sa.Well Location: /( tt ft
C I-11'h% c , `'er(-W i Cl . ft ft• F, -�..r `k .-l' .
• PacIity/ erName • Fatality DV(ifappliable) ft ft
n 0,.E ft. , 1, - i 2CeiJ
PI7'4a+Address,City,and Zip g .
itlr�:fi�3 ^Sr PF^::w3,e �I+rPr
alitjh ,2LREMARKS! i�:'�t.6�s7tir{is
C0 ' Parcel IdentiffiationNo.(PIN) •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]atllong is sufficient) 22.C
• 3 L' 3 2' .2 y_.•• N RI 9 _ 5 2 - w
�►''
3
.6 Is(are)the wags): ermanent• or OTemporary 7 36' Signabue 6.f .•.j".'Contractor. . Data •
Byslgntngthis'roimaherebyca t&that theueL'(l xas(nere)eonstrumedin aeeordmsewith
7.Ls this a repair to an existing well: OYes or Ol0 MA MAC 02C:0100 or7s f NCfC 02C.0200 Well Construction Standards and that a copy.
Ifthlsisarepairfill°Wann.t i well construction informationandceplain the nahaaofthe oft trreeordhasbeenprovidedtothewellowner-
•repairuoJderS2l remarks section eron the back ofthisform. ••
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells havingthe 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 Rdmarks Box).You may also attach additional pages ifne-r-Pes2ry.
drilled:
24.SUBMITTAL INSTRUCTIONS -
9.Total well depth below land surface: , 3 2.6 • (ft.)
For multiple wells list all depths(Jdi_pwrnt(esmnple 3 200'md20100') - Submit thisGW,1 within 30 days of well completion per the following:
10.Static water level below top of casing: 6 0 24a For All Wells: Original form to Division of Water Resources (DWR),'
!fwoferiavd is above caring sae No' ` •. (L) InfonnationPiocessuig Unit,1617 MSC,Raleigh,NC 27699-1617
it Borehole diameter: lam,/1 • (in,) 24b.For Injection Wells:Copy to D Unde
Program,1636 MSc.Raleigh,NC 27699-1636 rgmund Injection Control(TUC)
12.Welt construction method: 'f•a.h -J\ -•(i.e.
mBeS rotary,cable,direetpusb,etc. 24e.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the .
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: •
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• /^�/t 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) g ' Method of test: - Pelmrt Program,1611 MSC,Raleigh,NC 27699-1611•
I '- tr
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13b.Disinfection type: i1 Amount: i 0 cat/
lb
Form ow, North Canl•no TUn•••...-.....er__--.... ---. .