GW1--05796_Well Construction - GW1_20230901

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- WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Infortmitiolt I -
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D Pauli•e_O -g egs-mcmr, Rpf.t)_h . g--.1.e.i4.ui
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14.WATER TANKS I :
FROM TO DESCRIPTION
Well Contractor Name
1,43 ft" 0136 ft' Zi441iu-e' itat •
312-,A --7>ell?-C. ft. It'
NC Well Contra:UM CalifiMtionNumber
TS.OUTER CASING(for muIll-eaa-id Wells)ORLINFIt(if
(2_,1.04z- 1,4../44-.e& .,.,.1 LA:66,Q t.-ce_ FROM TO DIAMETER THICKNESS MAIFJUAL
ft. ft. 1 i in.
Company Name
16.INNER C.ASING OR TUBING(gaithennal closed-bon)
2.Well Construction Permit it 14-I Li-5K • FROM TO D/AMETER THICKNESS MATERIAL
Ltd all applleabld lid 1 constntetion pennits(La.UIC.County.Stale.Variance eta) +4 ft /36 ft /,!/ ' ' brz-zt it --
3.Well Use(check well use): • ft. ft. i in.
1
Water Supply Welk ' . 17.SCREEN
FROM TO DIAMETER. SLOTS= Tincfttness MATERIAL
I;lAgtjeultural 0Municipal/Public it. ----•--ft._ I in-
OGeOthennal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft. 1 18- - -----''.--------
Olndustrial/Commercial tlidential Water Supply(abated)
°Irrigation OWelLS>100,000 GPD FROM TO MATERIAL EMPIACEMENT METHOD&AMOUNT
Non-Water_Supply Wen: • e) IL
/56 fl- //it' 69 ' p o a :
0Monitraing ' °Recovery '
Injection Well:•
EL4Suiir licchalge - OCnotindivater Remediation
- -• 19.SAND/GRAVEL FACIE(KappliMbIe) .1.X.--.U).'lItii"""0
EtAquifiiiStOorge and Recovely °Salinity Banier FROM ' TO MATERIAL INANACEMENTDORNIOD --"kej
0Aquifer Test OStonmvater Drainage ft.=- ft.
SFP a 1 ?023 .
-----=-7-----..
°Experimental Technology OSubsidance Control ft. ft. 1
°Geothermal(Closed Loop) OTraccr - 20.DRMLINGLOG(athtelt amazing sheets ffneealliiil f ;li i 1---bwartg 1,:trti:
DESCRIETION(colat.bardnesa.nehoediPAcnkrtsTriitete.) -
°Geothermal(HeatinpXooling Return) 00ther(explain under821 Remarks) FROM TO
a
14,Rate.We11(s)Painpleted: ' Z-1-Z-3 Well Mt - . ' - A ft. _5" ILd' -,is .d.e-t7
... .. .., _...
Sa.Well Location: . ' . i :•ZOIL- -:-`2'•:6-4.- L'Es*---.' .S,FN/H:•'.- ••-e-V 4..-'-••• ,:- -.
:.:-2•ia:.• 41‘1B 4601-1.64:14 V A-14e-k - - it-. -i.-' .fi* .tg.ilUiel .-.'.'-••-•"" - • ' •.. ''''•• ••
Fnetlity/Cunier;14nnte' --:.' ' "-'' ;:. ,.. Facility IDit(ifnppliCable) . _.,_ :541,'!'i'! 1',14tY,,''':
ek5s 5-, o..1C31t/ p,ft-. iii.zft- 34e-AfsmIi ill 1
Phisiaaiiiiidi'cis:dtarip : : V,. ih a':f-L: 1 3-4::;I.i! 114-'10'&I/ '.!(1,--..,1014,145'„: 0 :.• ' •
jilapiCe al.. 1.16-32.0 2L REMARKS
13.P'16 6o .;. ,--
County Parcel Identification No.(PIN)
,71;-4--
5b.Latitude and longitude in degregs/mintitesIsecondi or decimal degrees: ,3 1/22
(if well field.one lat/long is sufficient) 22.Certificafion: ' I,
N w
/ ,,T 4-7
- /7.4 ,_
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ptv
. _,....-.
Somatnre of Catffied Well ContraCtor Date 3/-•Z.2--Z-".-
6.Is(stre)the well(s): 2Irermanent or OTemporary
Bysigningthisfonm I hmeby certifrthal thewell(s)was(were)constructed in aoctorlaneewith
7-Is this a repair to an existing well: i °Yes or EINo , 154 NOW 02C.0100 or 15A NCAC 02C.0200 Well Construction&anther&and that a copy
Iflhis le a relmir.fil I oat known well construction information and expkthrihe=Mir ofthe -ofthis'Ewa has ham promiged la the well owner-
repair wider al remarks sedion or on the back of this form
23-Site diagram or additional well Retall
8.For Geoprobe/DPT or Closed-Loop Geothermal WeRs 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 ofwells • (add'See°van in 4ealad°Bea)*Yea maY als°attach additimal pages if neeessa'Y'
drilled: 24.staaniTAL INSTRUelIONS .•
. . . f
9.Total*ell For multipl wells li depth below bind surface: 3 ie:5"st all depths fidgeted(example-3@,200 and 2@l00)
Submit this GW-1 within 301days of well completion per the following:
e ' : } I
,, ,,,,. 24a.For All Welke Orighull form to Division of Water Resources (DWR),
10.Stade-water level below top of casing: (0 a -
\ - 1144 Information Processing 1.Init,1617 toc,,galeigh,NC 27699-1617
If:water level ii above easing.use"+" I I - _ „ _
IL Borehole dilimeter:1
.24b.For Infection Welts:COY tolDWR,"Undetgaitrad Injection Control(WC)
•
Wellli. construction method.. /11W-/Al 6. 7
. . •24c.ForWater Supply and Open-Loop Geothermal Return Wells:Copy to the
(Lc::4YX**491PIY•,501..F.44.e(_*PurIbiciF), . ----: --f-- _COTO ERVINDMientrd.health department of the county where installed
FOR WATER SUPPLY VVELIS ONLY :.' ' ' 24d,For Water Wells prodleidnf over 1" 1 1 1 GOD:Copy to DWRz.CCPCUli
A ,.
- - Permit P ;Raleigh,NC 27 1611
rogram;1611M.W .''
Pl.!".YiT4P1130. '„ LIL -7 - - Method of test: -tt fi .2- . _
131t.Disinfection type: bda-01-441r-e.- Amount: 3 z-av,
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Form OW-1 1400.Carolinapepartment ofEnvitonmeoral Quality-Dit.ision ofWaterBesouslces Revised 6-6-2018
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