GW1--06489_Well Construction - GW1_20231013

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WELL CONSTRUCTION RECO (GW-1l.
1. Contract oa .. - For Internal Use Only, , j
C trot .>(�o ti( '""' I,.`-'--y' I
wenCo�actorName . •Id.WATERzoriES g1.
'TO ©DESCRIPTION _-
• 3:'. 3'5- t S ' 420 H I
NeweucoreantaN K re t
15.ODTER CASING(for ssintaKssIA wills OR LITER(Happleabic)FROM 1 TO fL M .iBSQQ,E,S I MATERIAL
CaapaayName I .
/► `, 16.INNER CASING OR
2-Well ConsbruotioaPermit#: .• T tDLIM(eeomerital doseddooa)
List allapplicable well eor6ueYon FROM TO . • 1DIAMErER THICKNESS , MATERIAL
permlts(Le.WC County,State,Yartmtr{eta) -I. I it. •117 ft ©�a e
3.Well Use(check well use): I! Thick(!� G a 1''1/ .
Water Sanity Well:, a h i 1 a 41.SCRIMS d!v ;a ✓-
• °Agricult ual ' . 'fM�micipayPublic - FROM [To artntalER SLOT SIZE THICKNESS MATERIAL
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°Geomermal(Seating/eool;ngSuPPIY) °Residential Water R ' j• .
OlnditstriaUCommercialpply(single) ft ft �•
°Residential Water Supply(fired)
°irrigation 1&GROVE y • •
Non Water Supply WeIL °Wells>lU0 000 GPD FROM TO •MATERIAL
�� / �I.+ Meaoaa<AMOUNT
• °Monitoring °Recovery Z3 1pp/���ea 4- M ;x {�
Iajectioawell ft.
t PO r' b:
°AqulfaRecharge °GroundwaterRemediation
°Aquifer Storage and Reeov y °SalinityBauier 19_SAND/GRAVELYACK(dapplXAL
['Aquifer Test FROM TO MerERIAL sesPldetat�xrrMErsoD
°StotmwaterDrainage ft: g
°F.zperimenlal Technology °Subsidence Control 1
• °•Geothermal(Closed Loop) • °Tracer
20.DRILLING LOG(attach additional sheets if necessary)
°Geothermal(Heating/CoolingReturn) °Other FROM TO • DESCRIPTION(ester•luaus,t.
(exPlainunderdF2lRemad�j ft. ft. a/reet�type. ,�eeta
4.Date Wells)Completed:IL) i
WeIIID# • ft A
52.Well Location: ft. ft:
Do-t,ible Bit T 1J a-�1 . l.� T
-I' B J�.h•V,:em i rt ` _ ft'• R, ii `I; I. ri :.s:.y F .'`..,' i �:'s'S -
• Faalih'/Owne'Name - - Fatality IDS if ]fable @ v k...�i�. .' �r ;" ?' .
Civr v --r •e e c • R L
Ply r R , •L� r �'f< 8CT .. Z�1 :.
i AAdf dress. and Zip ti ft in, i,;. j 7
V.)I. I I c-✓. • . - 2LREMARKS./ _ -_� f! 's
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Parcel Identifi cation No.(P/N)
5b.Latitude and longitude in deg rees/minutes/secands or decimal degrees: 11
("dwell field,one lot/long is sufficient) ;
C9 y. G r 21 j• G/` C 57 W 22.Certifca'on: , het
I N QU a 35 a
6.Isare thew /4-3"23 Is(are) ell(s): ermanent or °Temporary 12gQ Sigaatmbdf enCoataetnrl: ,
' Date
7.:YsthisarepairtoaagastiagwelL• °Yes :or signing forn.Ihim-0 4thrittheweUk)was(wcrc)col:n wed&aeeo tccwtth;
!Phis to ar •13.4M fC 02C:0190 or75.4 MAC 0.2C.0200 Web.'Conrnuenfon Standards mid that a,copy
epa/r,frll out brown well construction information lad nylofn the nature tithe lights=chi hat beenpn vlded to°the v it owner.
repair soiderf2lranarkr section oronthebaekof this foma
23.Site diagram or additionil well denials:
8.For Geoprobe/DPT or.Closed-Loop Geothermal Wells having me same -You may use the back of 64 page to provide additional well construction info
const<uction,only 1 GW 1 is needed Indicate TOTAL NUMBER ofwells (add'See Over'in Rimarks Box).You may also attach additional pages if necessary.
dulled:
t 24.SUBMITTAL INSTRUOTIONS •. '
9.Tofal well depth below land surface: D • (ft)
Formuftlplewell:psrall depthsifdlfjerort(armaple.g(�200• 2�pp) SubmitthisGW-iwitlun30daysofwellcompletionperthefollowing- ,
6, 0 • ( ) 24a. For All Wells: Original fo� to Division of Water Resources (DWR),
10.Static water level below top of acing:
lfwarerlevel it above casing:sac-+;f Information Processing Unit,1617 MSC,Raleigh,NC 27699-161T •
1L Borehole diameter. L -go • - 24b.For Infection Wells:Copy to DWI,Underground Injection Control(IUC)
- n Program,1636 MSC,Raleigh NC 17199-1636
1 .Well•conshvctioic method: R 0 4 Z.ill /r or•--
2 auger,sotary,cable,diced push.etc) 24c.For Water Snooty and Open-L`op Geothermal Return Wells:Copy to the •
(Le •
county environmental health department of the county where installed
• FOR WATER SUPPLY WELLS ONLY: •
�"• � � 24d.For Water Wells prodaeint=over 100,000 GPD:Copy to DWR,CCPCUA .132-Yield.(gpm) L Q 0 . Method of test: Cat Aft. P Pmgtam.1611 MSC,R?leigla,NC 2T699-1611
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13b.Disinfection e: '
nab I 1-4-
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Form GW 1 r
North Carolina De/utmeat ofEnvironmental quality-Division ofWaterrtesoarces. , Revised 6-6-2018
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