GW1--06270_Well Construction - GW1_20230926

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• SELL CONSTRUCTxON RECO (GW:1) For Internal Use Only:'• •
L Well Con Worms on: . 47lc:t;?t
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well el.
'14•WATER ZONES
Connector • e •PROM TO' DE CREEP'[ON , -
.. L 7 - •
• 1Gd ft. 3oDm 1i . ,
NC Well f� to ;
Contractor cation
• /t is.OW=CASINGSfor i ld-cased walla)OR LINER Of ap Unable)
CampanyName /lA�j! PROM"R I TO .� I DI1 MEr. Iin. rarcas Lis .� MAT!<1tiAL
2.Well Constroetion Permit#: �.�J �j q 2. 16•INNER CASING OR T[IDD7G(ceotherhmal doeeddooa) ' -
LisIoil appllmblewell eonrnueNon PROM TO bGhlyEriR I�QORSS MAISRIAI.
pont*:(ta WC. y,Stare,Variance,eta) , •
/ n •
0 R . 5Tr k. �h I r A p
3.Well Use(cheek well use): l h
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Water Supply Well: • aZ SCREEN •
• • °Agricultural '°Mimic' PROM TO DIAMtTTiE1ZRin. SLOT SIZE iffiLTQass MATERIAL rpal/Pub1Ic !t. ft ;
°Geothermal(Heating/Cooling Supply), idential Water Supply(single) • . •
Olndustria/Commercial ft ft in''
ResidentialWater Supply(shared)
lg,GROUT
Ofrigation °Wells>160,000GPD PROM To •
,MiATERiAL thfIL CDONTMITHOD&AMOUNT Non-Water Supply Well: 23 N( + 1 elf. —
. ' OMonitoring . _ °Recoveryft D M'.,X
Injection Well: P01^�'�hd' ?cub.,y,�(.
-' °Aquifer.Recharge °GroundwaterRemediationft. ft • • t
• °Aquifer Storage and Recovery °Whdty Bernier I9.SAND/GRAVLLPACI if avnlieable)
PROM TO MATERIAL lairlACIMT11'METROD '
°Aquifer Test OStolmwaterDrainage ' tt ft i
- °Experimental Technology ❑Subsidence Control ft ft. • 1
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°Geothermal(Closed Loop) • OTracer •
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20.DRILUNGLOG(attach additional sheets if necessary)
turdaa
°Geothermal(Heating/Cooling Return) . °Other(explain under#21 Remarks) PROM T71 0Nl ibalmsr,w0lneic bvr.Pala au?ate)
ft TO ft. DPSCR1
' 4.Date Well(s)Completed:. C) -'l? Z3 i ID Weil • ' ' ft •ft
Si.Well Location: • 2
'lb rnas �u.1•A. '/l/l a rim/ . • • n ft. . , •
FaclltylOwnerName FaerltylD (if applicable) ft. rti :J K.r$ fit' �Li '
PhysialAddre City.and Zip ft. ftI, SE( v kI 2023 '
(7... i . , . 2LREMAPJCS! I in`_ ter}Pr+^wy•91 URA .
County Parcel Ide• ntific•ation No.(P1N) rulathCZe3
5b.Latitude and longitude in degrecs/minutes/seconds or decimal degrees: id
(ifwell field,one laMong is sufficient) 22.Ce e ;
• 31 ' .211 '.53 •' N gig e / , W •
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6.Is(are)the well(s): °Permanent or °Temporary ,� /To '' Sigcsttve 6.f Wen Contractor • Date .•
- ' By signing thisforma bray cat*&atthe st:WOWas(were)eonratectedInaawd:an:8*dr
7.Is this a repair to an existing well: °Yes• or o' 15,4 NCAC 02C:0100 WWI N tC 02C.0200 Well Conmrxdon Standards and dart c copy
. Jfthls Is arepakfi l out known well'eoran'colonisation Information a'rd latm the nahbe of the edits record hat been Frew"to the well owner.
.. 'repair render VI remarks:anon or on the backgfthtsform. '
23.SIte diagram or additional well details: '
8.For Geoprobe/DPT or QOseB-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 Over'in Rtniarks Box).Youmay also attach additional pages if necessary.
dn7led:
• 7 24.SUBMrr'TAL INSTRUCTIONS• '
.- ''9.Total well depth below land surface: ' J 2.D . ' •
Formrddple well;list all depths tfd)ffer rat(emmplc_g®1p0•m,d2QI00) (R) Submit this GW-1 within 30 days of well completion per the following:
30.Static'Water level below top of easing: �n Q •• (R) 24a. For MI Wells: Original foam to Division of Water Resources (DWR),' •
Ifwarer[eve[Li above ear/neI use"+ter of
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 • '
11.'Borehole diameter. , Y 1/li ,�,) 24b.For Infection Wells:Copy to DWR.Und
Pro 1636 MS Ralei01 Injection Control(lUC)
1?A .� tom. C, gh,NC E2E7699-1636
12.Well construction method: / 4e.For Water Supply and Opent'Loon Geothermal Retina Wells:Copy to the
i.e.( auger,rotary,able.direct push eto.) I
. al ty environmental health department of the cotmty where'installed - - '
FOR WATER SUPPLY WELLS ONLY:. -
24d\Fir Water Wells producin over 160 000 GPD: '
Permit Pro Co to•D
132.Yield(gpm) I..5 • Method of test: e.L.A. .- 1 Program, MSC,Ratel�gh,NC 27�99-1611 l CCl?CUA
hT •13b.Disinfection type: Amount: O OV 1
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Form OW-1 North CaroliaaDepartmentofEnvisormental Quality-Division of WaterRaoo<ees Revised 6�-201R