GW1--07389_Well Construction - GW1_20231117

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` 'WEI •CONSTRIICTYON RECO (GW-1)
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I For Internal Use Only
L Well etoi:Inf rmatio • j '
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• •14.WATER ZONYS 11h i•.'
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�w TO ft° D�CR>lrION•
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ff tZIIC7Qrrec t MKlERr.r.
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2. Construction Permit#: �J• vl/ •
U.INNER CASING OR TUBING(geothermal doicd-loop)
2. l Well CUm tructi! OM TO I A DIAMETER THICKNESS MATERIAL
gut onpc:antra&WC Co ) -t/ S3
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. : 3.Well Use(check well use): ft •ft;
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Water Sn h Well: .
• DAgricultural �7.SCREEN 6�
PROM
OMImici-aJip :_ TO DIMMERin SLOT SIZE TRICE:MSS •
pal` • f. ft • y ; in- IIfA•I.11tIAL
OGeothamal(Seating/CoolingSuppjy) zed' R•
11�I Ohubshia CCommercial !a �� '°
tia1'WaterSupply(shared) IL GROUT '" UPI
Dlaigation Dwc11s>ion ono GPD snort TO
Non.WAter Supply Well: • . dare ra�LAeeAaQrr>u>-rsoa t.uNtouxr
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• alvtonitofing • � � b : .�,`� ft:
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Injection Well: ft • it 1 FOrf!?A mac,(
D Reeharg It (,.,,.�, •
a D�FdwaterRemediation •_ _ �•
DAquifeSta[ageandRtcovesy - - nsalini Earlier
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17AOa[ TO L' 4ZarAL IdC�IIiTldEISOD
DAquiferTest . . • OStormwaterDrainage •
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DExperimental Technology DSubsidence Control fc r
DGeothennal(Closed Loop) DTiacer 8 !
OGeomamat eatin 20 DRILI,nvGLoetamclllaaditiooa•
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(S P�CoolingBarium) OOfiler(eaplainunder#21Ramada)" nom TO •EIDLSCFOIMON(aar.Yardmen,seltukbye.vas sinet&)
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•4.Date Well(s)Completed: 1I-3 -U Well ID# '' •.• I I
Sa..Well Location: ft
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Facility it R ll�, C :J
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, .Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �1 Iv V
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(dwell field.one 1st/long is sufficient)
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n p / Cle o dG�Ce. r . • to �3
6.Is(are)the weII(s): Dpermanent or OTem o 1 ! S D
7.7s this a repair to an existing well: Dyes of . By signing dar :OHO
am.lthy Chats.o2oo(r)was(wan)conarnuedin acconia a w15,
!thtrlsa g 0 .-. ISA NOIC 02C:0I00 ar.7S.t C.02C.0200 WelI Con strualoa Stadmds and thane copy
I repair,fill outb,ona well construction b fornatlan and explain the nature ty'the edit roc ondhas baaprovldrd 'hewed metal'reinlr under 421 scnarkructionoran the bank*/slakforgc • ,
._ 23.Site diagram or addibogal well&taxis:- . -
8.For Gee-probe/MT or Qosed Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
• construction,oolY 1 GW-1 is needed Indicate TOTAL NIJAIDER ofwells (add'Sec Over inRBmarlcs.lax).Yon may also attach additional pages if necessary.chilled: • l��
I 24.SIIBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: •-/ '
Foro,tdtlple wells/!rt all depths/f Qpr(t�lP/e-3(aj200'tmd 2(a)(00� (f t') Submit this GW 1 within relays of well completion per the following: • " '
10.Static water ltwel below tap of easing:g: •
,, 24a. For All Wells: On form to Division of Water Resources (DWR),•
I/woarkvdlsaboveearl„y�tre/-+- 1 �/ JO ( ) Information Processing Unkl 617 MSC,Raleigh,He27699-1617" • •
• 1L Borehole diameter: 10 /p {m) • 24b.For Injection Wells: : py to DWR,Underground Injection Control(WC). -
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Program,1636 MSC, NC 27699-1636
12.Welk construction method: (' 0 7 ail— �•r.�.cable,dileapttsiti eta)' 24e.For Water Supply and nen-Loon Geothermal Return WeRs:"Copy to"the •
•
(Lc.auger.
• • county environmental health of the county vthere installed •
' . FOR WATER SUPPLY WELLS ONLY ;. _ •
• 24d.For Water Wells Iwo' dicing over 100,000 GPD:Copy to DWR.CCPCUA• - .
13a.Yield(gpm) ..S Method of test: •a A..47 " " Penult Program,1611 MSC. ,igh,NC 27699-1611
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13b.Disttifection type: I I I.'L f ✓ I
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Amount: 1"()
Fo,m GW-1' .
North Carolina Department ofEaviroam nt Quality-Division of Water, Revised 6• .2011