GW1--07123_Well Construction - GW1_20231101

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WELL CONSTRUCTION RECO (GW-11, For Internal Use Only" I
• 1.Well Contractor.Information: I
,.iltr.:40;11
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Well Contra ���� •14.WATER ZONES IrAi I .1 . _..
ame FROM TO DESCRIPTION
S35 • • e00ft �,10it f "
Nc Well Contractor Certification Number
/^� IS.OUTER CASINO(for auldd-cared welts)OR LINER(ifap livable)
i- 1 0 1-.•r •-. � FROM TO
i arAMErER I THICKNESS MATERIAL
CcmpanyNanu • ft. •
ft II ',. In,
2.Well Construction Permit#.�{7 I R (�'C 16 INNER CASING OR I NG(geothermal doled-loop) .
• ROJL• .(1 des () r !( 1 FROM . TO IDWHErER THICKNESS
List all applicable well construction permits(1.e.WC County, MATERIAL
slate,Variance.etcJ �- ft j 26' I 1a ST� j -C.1
3.Well Use(check well use): ft. ft • ,in. r Syr
Water Supply Welk 47.SCREEN
I
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• °Agricultural 'DMunicipaMPublic FROM To D1AMEiER SLOT SIZE. THICKNESS MATERIALOGeothermal(Heating/CoolingSupply) ft ft..
t in •
dential Water Supply(single)
Dlndustrial/Commercial II ra.
adential'Water Supply(shared) 18.GROUT
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°Ir igation OWells>100,000 GPD FRoM TO n ,
Non-pVaterSupply Well: UMA LACF1tigM114'iHODQrAMOUNT
ft L- - •
•-__ Oreille ring ORecovery_ - �� -----'-'• •'y ��
Injection Well: •- - ._. . , - . ft ---• =f� I---I- j-f d_ - _
447
❑AquiferRecharge OGroundwaterRemediation !t ft ./ ��
OAquiferStorage and Recoveiy ❑SalindyBalrier 19.SAND/GRAVEL PACK dapplicable) • • •
OAgtiferTest 0M To IUt, • . L FMPIdCIIHII4111>ETgoD
OStolmwaterT)rainage. ft. ft I .
OExpeiimental Technology OSubsidence Control ft ft. •
°Geothermal(Closed Loop) . - OTracer 20.DRILLING LOG(attach/additional sheets if necessary)
❑Geothermal(Heating/CoolingReturn) OOther(explain wider#21Remarks) PROM To 1DltscltzpaoN(r.1.ntw,anss,,roa/roelceypegr,;o,;mue)
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4.Date Well(s)Com leted: tb'2. f t 11 ..
B >f'-Z.3 Well ID# ,ft 'it. 1.
Sa.�Well Location:, - ft. ft Il•
J 1/►�t%vI Orin s '(fir sfi.G�, tz ft II
Facflity/Owner Name Facility MO(if applicable) fk ft I' i
37e �e-l-ride : �r'• N.-1 . ( ,.� ft II }� - r
r 1
Physical Addtess;Ctty;and Zip . ft Ar "'. i.r �� '
c ft" II IVY�/ �) : t...
(1 r • 21.REI14ARK•Sl� r 1 .
County • PareelIdeotifiationNo.(PIN) II ','l''`) 7':a,- l'n�J
Six Latitude and longitude in degrees/minutes/seconds or decimal degrees: II am'`' -''`'� ''3 tit :i
(ifwell field,one latlong is sufficient) ` '
3/a' 3// I Y' g64 .•t f6 a 22.tea-Mention: '.; fiviiiraig�
N �• W i Ardle I /a z Z
6.Is(are)the well(s):jermanent or OTem o 3
P Y 1 Z36/ Sigaahme bf/`' •e&' en Co Date
By signing this fonm1hemby c4lift that the well(s)was(were)consouctedin accordance with
7.is this-a"repair to an existing well: OYes or )1fNo 1S,t NCAC 02C:0100 or 7Sel C 02C.0200 Well Go traction Standards and that a copy
Inks is o repair,fr1 ma known well construction information cm14exPlain the nature of the VW"record ha!been provided o the well owner.
'repai►:o der121 remarks section or on the back of this form. .
23.Site diagram or additio al well details:
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8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of ,i page to provide additional well construction info construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER ofwells (add'See Ovet'in Remarks B.x).You may also attach additional pages if necessary..drilled: •-
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24.SUBMITTAL INSTR r . ONS • -,
. ; 9.Total'well depth below land surface: ' (:p - -
Formultiple wells list all depths if different(esampbr-3(a)200'and 2®100) •(ft.) Submit this GW-1 within 3I days of well completion per the following:
10.Static water level below top of casing•. G D • (K) 24a. For Ail Wells: Orly',.I form to Division of Water Resources (DWR),'
Ifweter level is above'easln�;nss"+" `,l Information Processing Wit, 617 MSC,Raleigh,NC 27699-1617 -
11.Borehole diameter. try ' ,(m.) • • 24b.For Injection Wells: o.py to DWR,Underground Injection Control(IUC) -
Program,1636 MSC,Raid:. NC 27699-1636_ '
12.Welk construction method: . .•
miser,ro
(i.e.
B .able,direct push,etc) 24c.For Water Su,, and a ,en-Lon.Geothermal Return Wells:Copy to the. '
county environmental health'<epartrnent of the county where installed _.
• FOR WATER SUPPLY WELLS ONLY: •
/ / 24d.For Water Wells prod)cing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) - t rs Method of test: f:1l�l.� Permit Program, MSC, eigh,NC 2T699-1611 " •
L !y
13b.Disinfection type: 14 7IT Amount: 1 6•
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• j " Form OW-1 • • North Carolina Department ofBAvhnnmental Quality-Division of Water Revised 6-6-20.18