GW1--04661_Well Construction - GW1_20230721

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WELL CONSTRO TTONRECO ( -11 . For Internal Use Only. . •
• L Well Contractorjnformati • ( "
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• •14 WATER Eons
Well CoettactorName h FROM TO DESCEOPnON
• 5 .?-7 A /�o Lo o ft.
NC Well Contractor CatifiadoaNup • ft i� .
III/1Jer
/� IS.OUTER CASING(for multi-'ased wells)OR LINER(if op limbic) •
CompanyName �•l`t/1 //K'�0y -Pal) FROM I TOft ft I DIAMETER- I TBIC[4YF.SS I MATERTAI.
2.Well Construction Permit#: C J S (/l/ 16.INNER CASING OR TUBING(ceotbermal dosed-loop)
De all applicable r well eon Permit
permits(Le 9Ula FROM TO DIAMETER THICIQ�IESS MATERIAL
Carm%.Slat;rarianee•eiq ..'f•I ft 1,7 ft. 5,7/y in• rA(e
3.Well Use(check well rise): 8 io. �.
Water Supply Welk 41.SCREEN
DAgriculttual OMunlCipBl/PObIIC - FROM TO DIAMETER SLOT SIZE TffiCIO�SS MATERIAL •
°Geothermal(Heating/CoolingSupply) ft. ft _ m.
dential Water Supply(single)
°IndushiaUCommewial ij 'ft bi-'
ResidentiarWater Supply(shared)
°Iriigatiolt 18.GRODT
°Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Welk
V^ 2-3 IL' °Monitoring DRec• ov �eG a' A.,i` �C:t'-- .
• Injection Well: ft, ft P6Y,'.M'. c7
• ' OAquiferRecharge 0GmundwdterRemediation f• rf
°Aquifer Storage and Recovery 19.SANiD/GRAVELPACK(ifapplicable) .
DAquifertor Test ery • °Salinity Barrier '- • • nom TO MATERIAL
OStonnwaterDlainagee . I ft ft.
En�I.►ceMErrrMEZBOD
DExperimental Technology ❑Subsidence Control • ft ft.
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• CIGeothemlal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Heating/Cool ng Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness,so�Uroek type,grain s oz•eta)
/ ft. ft
4.Date Well(s)Completed: (O-Pt-Z3 Well ID# • ft •
•g •
5a.Well Location: Ait • ft
LuCas /-knc CV s ail . ft .
• Facility/OvmerName Factlij1l#(ifappliable) per, �(
ft ft t'\ 1sI/
OmtNS 'Re, . Taryr-j 5 Rd. ft. -
Physical Address,City,andzp ft ft JUL 623
Lu i 1 1 1 t_._, • ,2LREMARKS/- _
County t" fT-n<t ?-�,.
PateolldentifiationNo (PIN) - ' DWQR3OG "g lira
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(ifwell field,one lat//ong'is sufficient)
i /� '. / e 22.Certification: •
..� o N !,' J 2• w I
{.6.Is(are)the well(s):7Permanent• or °Temporary 1 14 Q Sigoaomc' Ceitifi to �'3
i atracM Date
7.Is a repair to an existingBy riving thlriiirr, BoebyeoYifylhaf thewell(s)cress lucre)wraortcted fn accordancewlth
7 this this r well: DYes or ( o ISA NOW 02C:0100 or7SANCAC 02C.0200 Well Cpnnrualon Standards and that a copy
I epair,fill out brown well conmverion fnformatlon and fain the native of the ofthis reeordhar beenprovided/o the well awna-
•repair under$21 rernarbrration or on the'backofthfsform.
23.Site diagram or additional well details:
• 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells haviogthe 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 R iniarks Box).You may also attach additional pages ifnecessary,
drilled:
SUBMTrI:9.Total well depth below land surface: 0 • �• �'INSTRUCTIONS '
Formula:Neese&Bet all depthrifeltAran(exanple-3(aa2200'and 2pl00') (ft) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 2,6 • -(,) 24a.-For All"Wells: Original form to Division of Water. Resources
limner level is above carfn&'rae..+- Information Processing Unit,1617iMSC,Raleigh,NC 27699-1617 • � ), •
11.Borehole diameter. 10 I}� • {m.) • 24b.For Iaieetion Welly Co
q- - PY D99-I,Underground injection Control(NC)
12.Welt construction method: 1 0 a Program, MSC,Raleigh• ,NC 27699-1636
(i.e.auger,rotary,cable,daatp� ) f_ /T�►� • 24a For Water Sn and O en-Lon Geothermal Return eotmty environmental health de parhnent of the county where installleed Copy to the •
• FOR WATER SUPPLY WELLS ONLY: •
/+ •
24d.For Water Wells urodncine over 100 000 GPD Copy to DWR,CCPCUA
13a.Yield(gpm) 15 Method of test; /.(� '(,t P Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 1+1 14 . Amount: SP 11 ,
•Form GW-1 •'
North Carlin.n:........-. ---..... ..