GW1--05126_Well Construction - GW1_20230818

Y
r P TCTION 191 fPM R —For Interna�-- 1 Use Only: __________. _.._.__..______.____
04
I Well ll ,ci�llrartaat►4R _.. _ _._ -----
`i ... r Ik v•a'4 -.9 j`.' f t --------- Mom OM t0 DRSGPtl"TOH_ _ -�[°'�
v�f""* • xu nR it ��� ft. I hraPM .i�2
x ft fr�2 GPw+
is.OUTER CASING for multi ca xd — DR LINER(if op Licahlel
frn � .itttiOtaY(�$fic6Liolt Number FROM TO DIAMB'I'!&R TtIIC;Krr•E53 � MATERIAL
YADi(P4 WELL COMPANY,INC. ____—
ft, ft. in. ......
^�'^'�" 16.INNER CASING OR TUBINGSgeothermal dosed-loo ff______�
Name ` y ^ FROM TO DIAM,/LTER THICKNESS _--
`� lingaltalll 6SA) in. 6.NV
2.Well Construction Permit#: __
..!Al 0!1 applicable wall ewtrtructfan permits(w°•LIIG Cou State,Variance,etc) ft, ® in. 1
3.Wdi Use(check well use): 17.SCREEN SLOT SIZE THICKNESS MATERIAL
17.S TO DIAMETER
ClAgrSuppty Well: ft. in. _
❑Agricultural ❑MunicipaUPubtic — _
esidential Water Supply(single) ft. ft. tn.
❑Geothermal (Heating/GoolingSopply) DResidential Water Supply(shared) 1B.GROUT
❑Industrial/Comrrteccial • 18.G TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri.ation ❑W/el'ls>100,000 GPD �� `c P1 Poo re.) bt S
Non-Water Supply Well: [_��+t • e� �4�' 24, ft. CDwck Gtdk1( Pu(f'1rci 4 ri .Gc,
❑ ecovery
❑Monitoring _-— ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a liable) EMPLACEMENT METHOD
DAquifer Storage and Recovery FROM TO MATERIAL
❑Salinity Barrier ft.
❑Aquifer Test ❑Stormwater Drainage ft. —
ft. ft.
❑Experimental Technology
❑Subsidence Control ._.
,Tracer 20.DRILLING LO attach aacitiona]sheets if necessary
)
❑Geothermal(Closed Loop) ❑ Ii!.U
TO DESCRIPTION corer,hardness,soiVrock •G: aia s u,etceatin Coding Return) ❑Other(explain under#21 Remarks) ft•❑Geothermal(H P� �
'74�03 Well ID# — 508 8g ft. 101 ft reanv4e'
4.Date W Completed:G--- as �3 ft. Tan (je)C,�C
5a.Wellll Location: / Phone # / ' '/03 ft. Jed G can ti tr.
f G 4 C ft _ ( ' '� '�
Facility ID#(if applicable)
Facility/Own N ft. ft.
NA' - �t ft. A U G
-� � pr —
Physical Address,City,and Zip Nt,r Ai4i"'2 21.REAiARILS
��'�� lr►hrwraL:- ?rx
Parcel Identification No.(PIN)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22.Cer: i .
•
(if well field,one 1at/long is sufficient) �p a 9 a 3
�/ /?- QS!-C'2 N W u .
Date
�,( Sign tore of ertined Well Contractor
6.Ls(are)the well{s): �IYermanent or ❑Temporary By signing thisform,l hereby certi that the well(s)was(were)constructed in accordance with
( ISANCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a copy
7•hi thisi a a repair to an vm wellg well: ❑information d p the nature of the
of this record has been provided to the well owner.
repairexplain under#21 remarks section or on the back of this form. You may use the back of this page to provide additional well construction info
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
(add'Se Over'in Remarks Box).You may also attach additional pages if necessary.
construction only 1 GW 1 ins needed. Indicate TOTAL NUMBER of wells 24 5� T�INSTRUCT
drilled: ----
9.Total well depth below land surface:
SL` (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 c©200'and2©100') r All Wells: Original form to Division of Water Resources (DWR)
10.Static water level below top of casing: ' 24a. Fo
(ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
(� "]S 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC
If water level is above casing,use"+" Bit Off: — NC 27699 1636
11•Borehole diameter:
(in.) Program,1636 MSC,Raleigh
AIR ROTARY 12.Well construction24c.For Water§1-a- and O en-LOOPGeothermal Return Wells:Copy to to
cable,
direct
method:etc.) county environmental health department of the county where metalled
(i.e.auger,rotary,
FOR WATER SUPPLY WELLS ONLY: 24d.For Water bell roducin leigover
000 000 FD• Copy to DWR,CCPCU
Permit Program,
11
_?" Method of test• _ f�t/
13a.Yisi echo OZ DATE SITE VISITED:
70%HTH Amount: /f '
13b.Disinfection hPe= '' ISI ED BY: f/
Ravised 6-6-20
pr1 f rats]Quality-Divs!on ofWalerResources
Form GW 1 4