GW1--07119_Well Construction - GW1_20231101

•
WELL CONSTRUCTION RECO {GW-11 ,
For Internal Use Onl ' I; ' ' ..
1.Well Contractor.Information: •
•
' Well ConhC 'follow •14.WATER ZONES II i.
FROM TO I DESCRIPTION V
• " - ` _3-5.3 5 hod ft' �ob fa I I ;
NCWenContractorCeccfcationNumber. ft ft
,'. .�;,, IS.OUTER CASING(for mute-eased wells)OR LINER(if an livable)
`I L•A+ 7,J ctiv 13'7.- 'i \iV" - FROM TO - JiI DIAMETER TfClClESS MATERIAL .
Compai rName • ft I ft 111 1' }- �• I
2.Well Construction Permit#: L• •� 16 INNER CASDVG OR BIIVG(geothermal dosed_l000) - •
eri 3 (a .Cf Y-L FROM TO YI DIAMETER THICKNESS MATERIAL. i
List all applicable well construction permits(i.e,WC Covey,State,Variance,eta) ft 53' ft• m
-t� 117 /8 • ;
3.Well Use(check well use): ft ft' �, .
Water.Supply Well: 1
A7.SCREEN II
•
DAgricnitural • FROM TO' DIAMETER SLOT SIZE THICKNESSMATERIAL
bMunicipal/Public •
ft
°Geothermal(Heating/Cooling Supply) residential Water Supplysin le 1 . m
OIndustriaUCommercial ) ft.
( g ,
OResidentietWaterSupply(shared) ft •ft 111,' .,n . • •
' °Irrigation - 18.GROUT II +' •
°Wells>100,000 GPD FROM TO IIMA 1 i.tam MrM rRoD&AMOUNr
Non-Water Supply Well: ' • '
• OMcnitonng (J f_ Z 'it- II ea t•-- -AA "�C�•e t� - _-
• °Recovery
' Injection Well: ft 1 D w/�P.t
ft ft. r L t '''t
. °Aquifer Recharge OGroundwatei•Remediation / '
°Aquifer Storage and Recovery Dgalinity Harriet 19.SAND/GRAVEL PACK$dapplieable) • •
FROM TO (MATERIAL II.QIAcmIFRFMErSOD
OAquiferTest OStonnwaterDlainage - ' •ft ft fI
°Experimental Technology
❑Subsidence Control ft
• °Geothermal(Closed Loop) • °Tracer f t II
20.DRILLING LOG(a ttacliadditional sheets if necessary)
°Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remadcs) FROM TO iDESCRTpTION(color,hardness,soilhoe k true main sin eta)
..• ft ft II i ,.
4:Date Well(s)Completed: /D.0-•Z3 Well ID# • ' ' ft •ft% III • .
• Sa.Well Location: , y it - • • ft II•:( CIf rna h • .M.a.r l len - .. _ • ft ;ft •ll�� tZ : ;.3
Facility/Owner Nam-
Facility ID#(if applicable) ft ft NOV
I . ,-^c a. ^s.,1
1?-e eV-e s- Arbil ) Q ..f< . ft II N�V � _ :
Physical Address,City,and Zip • (i ft. ft 11 1 J , ,,-) �f��� '
S to t,..,.. :. , 21.REMARKS! I
Parcel Identifi i'1
• Countycatioallo.�� I1 .i" r
•5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - ll i` '
(ifwell field,one lat/long is sufficient)
22.Certification• � � '�
�i' 9 N fib'- 3Z: 3 - W , 4+
•
II I r: o --2. Z�
6.Is(are)the well(s): 9 rmanent• or °Temporary' • / 2. SO ' S• • f • Well Co 'ctor •_ Date
II Byrign1ngthisforn,lh thatthewe:(s)was(were)compacted in accordance with -
7.Is thiis.a repair to an existing well: - Dyes or o ., ISANCdC 02C:0100 orrlsAReeic 02C.0200 Well Conurucnon Standards and that a copy
Ifthisisa repair,fill out blown well construction information explain the native tithe••, of this record has beenprovldet the well owner.'repair tmder 021 remarks section area the back ofthisfons. - • �I
' 23.Site diagram oradditio a1 well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same.' • You may use the back of th s page to provide additional well construction info :'
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks B x).You may also attach additional pages ifnrrrvss y
drilled: •
24.SUBMITTAL INSTRUCTIONS
• 9.Total well depth below land surface: • 2 Z Q • ' ;
'Formullp/e wells list all depths ifdii different(=ample-3@200'and 2Q1009 ' (f t) Submit this GW-1 within 3(I days of well completion per the following:
24a. For All Wells: Original,h i
10 Static water level top of casing: (o"0•
' (�) form to Division of Water Resources (DWR) '
Ifwaterlevel/s above Basin&;usa°//+"t` Information Processing Unit 11617,MSC,Raleigh,NC 27699-1617 .•
11.Borehole diameter. (9 24b..For Injection Wells:.do�' .(in.) p to DWR,Underground Injection Control(BM)
;'� Program,1.636 MSC Raleigh NC�27699-1636
12 Welt construction method: I�O' v •
(i.e.:ages;rotary,able,daectpusb,ate,) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the '
county environmental health department of the county where installed -• -
• FOR WATER SUPPLY WELLS ONLY: II 1 •
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA `
13a:Yield(gpm) 1 5 '- �..-' Permit Program; MSC, el NC 27699-1611 . "Method of test: Pf�►, is
13b.Disinfection.typee 4i '4 Amount:
Form'GW=1: North Carolina Department ofEaviroamentil Quality-Division of Water Res Revised 6-6-2018