GW1--05881_Well Construction - GW1_20230918

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• 'wEIL CONSTRUCTION RECO GW-1 .
-�-� For.Internal Use Only+"
L Well ntrnctor. rmation: ( - j
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Well Coenauar •Di.WATERZONES tl . t I •
FROM TO I DESCRIPTION - �•
.35. 3 5 /oo :•Iyzo it 1 1
xe weu Canaaetor Cespggp�y I.1
c
�/ 15.OUTER CASING(for multi-eucd wells OR LINER firm, Gobk1 •
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J �Vj FROM I TO • IO D �.Tatman= 1 MATJDNL
mpaayName ft. 1, is
2.Well Construction Permit#:_ / rF / 16.MIER CASING OR TUION erica'doieddooS)
List all applicable well eenr4srcelon ! FROM TO THICKNESSIIrATF3rAr,
pa»ar(La WC Cowuy,$late,Ywiance.ere) ft. L f 7 8 [ " ��
3.Well Use(check well use): •�, S'9 in �ti its., j7 re---WaterSupplyWefl E` tt I 'a !
,17.SCREEN ' '
• • °Agricultural ' FROM TO DL3fE'1ER SLOT SIZE Tm 4Municipal/Public •ft .ft j1. in. CRNESS deveraIL
OGeothe mar(F�ing/Cooling Supply) .7�� lent ,Water '10 I
OlridustriaUCommercial Supply(single) it, .
rdential'waterS f` [I i` iv.'
Olrrigation Supply( d) ii GROUT
Owells>100 poodle GPD • FROM TO Non-Water Supply well O (MA. FnieLAcmm n eoD&,ruolnrr
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• • OMonitoring ORtxov f` 23 '' e(7 • M","1(t f
Injection Welk• - ft. ft
• • . DAquiferRecharge .f< _ Y 1t
la t A ( /� -f
OGroundwtter Ranediatioa • a II j
OAquifer Storage and Recovery OSalinity Barrier 19. •
MD/G��LPACKCM''a„livable)
OAquiferTest NEONTo r1rAT1 RlAL 1rACIINlNM fE18oD
OStoamw+terDisiaago tt ft f` II
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OExperimental Technology DSubsidence Control' 1MMl
ft 11
• DGeothelmal(Closed Loop) OTracer 20.DRILLING LOG(attach 6ddit coal sheets if neuuary)
O Geothermal(Heating/Cooling Return) OOther(avian tinder#21 Remarks) FROM TO • DESCrtn'lION(abr.ha daev,"Wreck
type.Rrar,smc.ere.)
it `I
4.Date Well(s)Completed: %L• 2 3 fe J • r I .
We11ID# f< ' II
5a.Well Location: •
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'D a h ft itI !.
F ('_al!a -an . R �I. .,-n;
aeaiey/O,VDefl^ii�E • E �' ) ^-a i•.'•! ,,...
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Fac7itylDi(ifappliablc) r R g fl: 'it......; `. '
Q Jr.- p@ itj Rd ..it l
Physical• � tN�vi I. S E P=1 8'1023
t4IIl • !I
l 1•!At1 a ► I 2LBZMARICS! �� "Rt`�`s' c7 °^-s�-.';�1;� ,
.J r,..,T Fx�.,•County •
- wr�-.9�.. • .
Parcelldentifina°nNo-(PlN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:•
LI
(ifwell fief one lat/long is sufficient)
34' '3 t ' 5 3 SO' 5 Y•2' 22.C tram:
N � ,
W � . . _l3-23
6.Is are the wells) 4?42 &ør.tI" •Is(are) [ ermanent or OTempornry 1 SigowaeofC• uhficdWelContractor Date
7.Is this 3 repair to as eidstia �U BY'ai C 02C:o o Ihereby I thct tlr 0200 )war(here)Conroueteak aecordmreewtdi
I this this
r g well: OYes or • No 1S.tNCIC 02C:0100 orr7.14V�lo C 02C.0200 Well COutruaroa Srodmdf and that a Rpy
f epair.fat out brown well conrpuu/ott p forysayyn the nature of de . oftbisrecordhas beenprovlded the well owiw:
•repair under VIranartrseetlonoron the hack ofdi'corm: , _ i
23.Site diagram or additional well detans:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of thilt page to provide additional well constmction info
construction,only 1 GW 1 is needed Indicate TOTAL NUMBER of wells (add'See Over inRbmarks Box):f You may also attach additional pages if accessary.
dolled
ift Z D 24.SUBMITTAL MST-RUCTIONS •
9.Total Well depth below land surface:we •
(ft)
maltiple wells llst all depths ifdl�erent(�p� 3�00•and 2(a)100) D
Submit this GW 1 within 30Dldays of well completion per the following: , ,
For
10. •
Static witty level below top of easing•. / Q 0 • (,) 24a. For Al! Waist Original form to•Division of Water Resources (DWR),lfwoter level is above earbib w i-+��, Information Processing Unit,11617 MSC,Raleigh,NC 27699-1617 • '
11.Borehole diameter. to {m•) - 2.4b.For Infection Wells:Co py to DWR,WR,Underground Injection Control(IUC)
Program, MSC,Ralei
• 12.Well construction method: 13 0'1 Ll r �, �. lk NC 1
27699.1636
' (i.e.auger rotary,cable,direct push.etc.)
_/ 24e For Water Suaplvmad Qaen-Loop Geothermal Return Wells:Copy to the
county environmental health d`cparfiaent of the county where installed
. FOR WATER SUPPLY WELLS ONLY:. 11 I
^ 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA -
. 13a.Yield(gpm)• ' ( Method of test ( ill •• • . P�Pr'ogram,1611 MSC,TeI5hNC276994611
• I _13b.Disinfectiontype: lk ( 14 Amount: lO (✓ .. . -
FormG '1 / 7 6- • • j;
North Carotin;Deps►tmeatofEuvitoameuhlQua]itY-Divis ion tafWataRes "
i. Reviud 6-6.201i
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