GW1--05976_Well Construction - GW1_20230912

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'WELL CONSTRUCTION RECO (GW-1)
For Intexna1 Use Only: }
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L Well Contractor. ornratio
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Well eonnaetorxasoe " 1a.WAXER zoNEs eI .tl
3•S �� FROM TO tlIDFSCRD'7ION . __
/OO fe'.26v f` II pl f
N ell Coutractos--7—timn R f• 41 p
ee--__ -- 15.°VEER CASINO(for multit-eased wens OR LINER(Nam Vocable) •
•yl/✓' FROM I TO gIDIAMEITR THICKNESS MA•r.<Q•A
campaa„Name 22 R I it I • irL� •
2.Well Construction Permit#: J� G 3•
16 INNER CAS/NG ORTUBIN erneal doieddRop)
Lirealll Construction
Permit#pumltr(Le.WC FROM TO THI T L
away.State.Yai1a c eta) 4-1 f` I 03 m 115Ty' i' �8 IV(a.'h T .
3.Well Use(cheek well use):
ft:
Water Supply Well; ft' , in'
scREEN • II II
°Agricultural °Municipa)/public - FROMfi. TO DL(?di rER sLOTSIZE THICKNESS MATERIAL ' '
°Geothenaal(SeahnglCoohng Supply) -I/residential Waterf •-11 1; 1a-
°IndustriaUCommetcial Supply(single) ft. it i, io.'
l]ResidentiarWater Supply(shared). II
�]irigation 18.GROUT II i- i
Noa Water Su Dwells>100 000 GPD FROM TO
PPIy WeIL 0 ft 7i.j fe• n�M.'i rrMel$oa 6cAMormr
• • Monitoring °Recovery I GGIY /1/�; *p(
Injection well: ft.
' ft. ?°ill net
°AquiferRecharge OGroundvraterRem lion -ft.: ft. II r T L /t
°AquiferStoiageaadRewvery °Salinity Barrier •
• 19.SAND/GRAVEL PACKCfapplicable) .
°Aquifer Test FROM TO MATERIAL YMPLSCIIdIIrr METHOD'
°StormwaterDtainage ° ft ft II
°E,xperimental Technology °Subsidence Control it fn• 11
.• QGeothenaal(Closed Loop) °Tracer . •' .
❑Geothermal 20.DRILLING LOG(attach additional sheets if necessary)
(Heating/Cooling °Other FROM ' TO • DESCtt11?TION(u6r.basdn
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Q (explain ess,sainektipe.minsize.at) ' .
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4.Date Well(s)Completed: !—�-Z3 Well m# ft 11 I'
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SL.Well Lontion: •
Jill W . � •R II '
f _
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I x Name
I ae;lit r lD (Ifappiieable) R {I ' f S E P 7 7
ilTi .•21 -( Sk w /D(,bh - 4�IookS -•ft- ft.- t r- I.
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P City: and TapI -
e ) �; R II'; lTi(iiiiFAk{Ci1't�f(:Sgq UfR$
• Z T Gj►'J 21.REMARKS! . II . . i31 s t:0-.,
eoin , d PacelldcatificadonNo.(PIN) . • ' "il• iI '
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 11
Ofwell Sold,one L•t/long is sufficient)
G7 3G 24 N 22c• r.car,n: t
k Gb o/ w '
i I; � Cam_ —Z 3"
6.Is(are)the well(s):4 Permanent or °Temporary Sigma bfCatified,11 i . Date
7.Isthisarepairtoan `eldstingwelL• °Yes or ' o 85'•d8nIngrhtrc:oloohere.bycatf•tfo c.o eU(sJwargiverejcanasta:ainaeeodacewuh
!fair Ist this
re IS.t Lrr 02C:0100 or73i1NCIC 02C.0200 Well Conr#uedon Standards and that crimpy,
pair,filloutbmrsrwelleoravualonWonnationand laln the#a0oxmftie ethfsruadharbeenPmvided thewell"ner.
•repairunder 121 remantsseetfon Gran the backof r/dsfonn
23..Site diagram or additio well details: -
8.For Geoprobe/DPT or Closed-Loop Geothermal Weds having the same You may?use the back of this age to provide additional well eonstntctioa info
consuuatipn,only 1 GW-1 is needed Indicate TOTAL NUMBER of wells (add'See Over'in REodarla Box), m Youay also attach additional paves if necessary.
drilled:
• 24.SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: •:AD,V • ft "
For multiple welltllsf all depths(afferent(cm#ph-3(d2t�•mid2�00) ( ) :Submit this GW-1 within 30 days•of well completion per the following:
10.Static water level below top of casing.. 0 ( ) 24a:For All Wells: Origins II Form to Division of Water Resources (DWR),
(wore;revel is above ea f„&;vrc/�-�/• Information Processing Unit;;1 1714SC,Raleigh,NC 27699-1617. •
• 1L Borehole diameter. V f m, 24b.For Injection Wells:Co" }to D )
L /( • Program,1636 MSC,Raleigh;f0 27699 636 d• ejection Control(IUC
12.Welt construction method: 1- /4'17
(i.e.welt rotary,atilt;diseet etc) 24e.For Water Supply and O�lea Loop Geothermal Return Wells:Copy to the '
• county environmental health d"ailment of the cotmty where installed
• • FOR WATER SUPPLY WELTS°PLY:. f i
• 24d.For Water Wells producing river 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) .I ' I Method of test (J A/.. Permit Progl'elm,1611 MSC,Raleigh,NC 27699-1611 lti
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13b.Disiafeetion type: / - .
Amount (�� ' ''
Form GW I North Casolma Depuomeot ofEnvisoscmenta►
Quality-Division of Water i• Revised6-6-22018
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