GW1--04780_Well Construction - GW1_20230724

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WELL CONSTRUCTION RECO (GW-1) For internal Use Only: :
' 1.Well ntr • r.In : 7eirY`� I I"
O�Y�� CC. • •14.WATER ZONES
FROM TO DESCRIPTION
WellContoaetorNeme •
MO ft' Jr��ft- •
3C35 • . • n n
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NC Well Contractor Certification N er 15.OUTER CASING(for multi-eased wells OR LINER(if ep noble)
•' • `t", FROM To DIAMETER THICKNESS MATERIAL.
T/�"� A
atAArh
Company Name p 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: D I7 ?.5-! --• C 23FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.e.WC,Cormry,State,Variance,eta) "1-I ft.
/QQ It. ,67/1Ci°' j l-e(.L 0vi .
3.Well Use(check well use): ft. R. in.
Water Supply Well: • e17.SCREEN -
FROM TO . DIAMETER SLOT SIZE THICKNESS MATERIAL
•• [Agricultural Municipal/Publicft - ft .- in
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft r ft in-'
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[lodustrial/Commercial Residential'Water Supply(shared) 1S.GROUT •
l7lrrigatiop [Wells>100,000 GPD FROM TO MA / t �L
EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ' O ft. 7 3 n ect r ' ,. 14 �
• ❑Monitoring ❑Recovery ft. ft- V gyp(ur, �v L
• Injection Well: R ft. ( 7
' ❑Aquifer Recharge . ❑GroundwaterRemediation •
• 79.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery . °Salinity Barrier • ' ' FROM TO • MATERIAL EMPLACEMENT METHOD
OAquifer Test ❑StolmwaterDlainage it ft. ,
°Experimental Technology ❑Subsidence Control ft. ft
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• ❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
PROM TO • DESCRIPTION(color,hardness,soil/rock type,Brain size,ate.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) n R
4.Date Well(s)Completed: 7.7- 23 Well LW ft. n ,
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5a.Well Location: ft. 5nnt's
J'•,( "4
. . ail..24L) S F....p..)1A) . _
• Facility/Owner Name FacilityMA(ifapplicable) ft n"
YRA I 1 •f lee(''RA • ' [ 3 71 •"+ n V ;
Physical Address,City,and Zip ft .ft
104 �c.lYl • ,21.REMARKS! �'�� ��LJty . Parcel Identification No.(PIN) I f' z r'1 Prr-;,� .u.•,• r Dt.A.V3C(3 l r
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: '
(if well field,one let/ong is sufficient) •
,( 22.Certification: 1 • •
3 6' IV . 5j-'�N tXa ' (-2' 16 ' w
411edteit f-444ffe4vk' 7-- 'fl- 23
.6.Is(are)the well(s): ke.rmaneut or ❑Temporary S(guature;' �ss'•.VVe Conractor D■te •
]� ( V/ ( ' Byalgning this form,I hereby cert),that the wells)was(were)constructed in accordance with
7..Is this a repair to an existing well: ❑Yes or Otto ISA NCAC 02C:0100 or 1SANCAC 02C.0200 Well Construction Standards and that a copy
gilds is a repair,fill out known well construction information ar(d lain the nature of the of this record has been provided to the well owner. -
•repair under CI remarks section or on the back of tltis form. '
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 1 GW 1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in R6marks'Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL '
INSTRUCTIONS • •
9.Total well depth below land surface: 5 Z( (ft)
For multiple wells list all depths ifd((ferent(example-3(4)200'and 20100') Submit this OW-1 within,30 days of well completion per the following:
10.Static water level below top ofcasing: CO 6 • („) 24a.-For All Wells: Original form to Division of Water Resources (DWR),•
Jfwater level is above casing;:use"+" (f Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 •
11.Borehole diameter. 6I� 0 .(m•) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
�� Program,1636 MSC,Raleigh,NC 27699-1636
12. -
(.e Well construction method: l 6��1. 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e,auger,rotary.cable,direct push„ato.)
county environmental health department of the county where installed
• FOR WATER SUPPLY WELLS ONLY:. ..
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield m � �� Permit Program,1611 MSC,Raleigh,NC 27699-1611 .
(gp ) (",'- 0 Method of test: tr
1011 6 (C) -
13b.Disinfection type: 7 Amount: '��