GW1--07749_Well Construction - GW1_20231201

•
WELL CONSTRUCTION _ • � �
STRIICfl0N CO tGW-11 For internal Use Only;
L W Contraeto Wormatio • i I .
• ..11 9.4.WATERZO1tES p ;
Well ConhaetorName PROM TO I DESCRRIION '
35 35 /avR• .-.20aR -
NC Well Com raeeor Ce tificanenN g !!
/,/a ti n ` A U ROUTER CASING(roc ao OR LINER(Nap Goble) •
!w W.r C,' . /[ TBYCmUSS R!A•[ERIAL
CompanyName: I • •
R I R y ! m
2.Well CoashroctionPermitmft: 3 �'I 5 1�INNER CASING ORTOBIIHG(aeotltamal doled lo•a)
llrtdloppUmblevdleatrArrrrlar PROM TO ADIAMETER THICKNESS MATERIAL ptaadtr(Lc.EEC Comity,Stak nofteta,ere) 4 I .R 33 R' 1 , 7a. ;a,
3.WellUse(checkwelluse): �irs` pee—
�. R R in. /
Water Sup ly Well: a7.SCREEN
OAgriculhual Ile , . .. • blic PROM TO Dl4afgr t SLOrSIZE 7ffiCIOG SS MATERIAL
DGeotbemral(Heating/Cooling S R it ,.
j( in
Supply) -;'detaial Water Supply(single) •
OladmuhiaUCommercial b R !t ! io.'
V. ' ••'mum Water Supply(shared) • I.Olrrigation 'Wells>100,000 GPD. ; sROM IL RODT p • •
. Non-Water Supply,Well: TO uMAuI elErsoD&.tMouxr
OManitoring ORecm ejy 0 fe Z� :z 8 e al- M. j A-.
Injection Well:
R. R 9 0fil Ud(• p.U/►'+•p.c A
• ' 0AquiferRecharge OGroundwaterRemediation R ft. 'Il
OAquiferSbnmge and Recovery OSaliaity$errier• 19.SAND/GRAVEL PACKOfapplieable)
FROM I TO IMAI7DIAL IIOIdCCHIIITMETHOD ..
OAquiferTest
OStolmvmr�terDtarnage _ • it. ft. ,p
• °
OFxPerimeatalTechnologY Subsidence Control • R 1
_
II R: '
(Closed.Loop) • ©Tn 20. �TO LOG(oflaelihdditiooal shear ifneeecsary)
(Neatia g/Cooling Return) O
OGsothermal Other(explain tmder#21 Remadrs) FROM • mtSCRGCii011(r.br.><ariem, uv�aelc h o4 uya s a,ee�)
4.Date Well(s)Completed: II-/"`23I R 9 I; , '
Well ID# • ft. ft .
• 5a. ell Location: • R R '
• • 1--erb I- 7vwrlsehd •
R. • R. �: CC
• • Faality/OamerName Facility RV(ifappliable) I ft. ft. .
hB1 Ra c1...-'a5NA„,, bib/t>..va-C 1 ., - .. -:•R ft. „ .. , °•� = 20Z3
. , Physical Address,City.and rip • w W d L t'`� �)Y • R ft. li I R vv r,�,,..:,ii i•';' -
C4J �a61 CI a: !.reeh'hr'Ii -D ) - . . 21:UNAR 1 , 1 ',.'w..� '~ �.,.
Co LiPneelldentifiadonNo.(FIN) I�II
5b.Latitude and longitude in degrees/loinu tes/seconds or decimal d �' u
' . ' (ifwell field,coe ladlongis sufficient)
• 22.Certification: .
31r y �N
6.Is(m)thes 'j II W , . . : �` l Date ZO �3' •
viellO•.�Fer naaent .or OTemporary !E
ll I Ageing Oitr om,lh II'
7.Is this a repair to an existing well: O es or jo ' 15 �' d C t�54 N 4C of theveu(i)vac O en)aoroosouedtn aaoordareev/th
rats a 1SANCAC 02C:0100 or.7yf Nh'ACO2C.02001Fa!/Cparintafoa Stadar*and thy a copy
j repair,�lflotebroMnwelloor�ve0pt/ p�at<onmde pfaLsrhemacee dim.. - .1 *+rrordihii'beaiprividadp"wag"'nen
. ' - •repa/rv+dr102lrimarkescyonor°a the back gftiiisfonsi . p
Il 23.Site diagram or.additional well details:
8.For Geoprobe/DPT or Closed-Loop.Geothermal Wells having the sane.'
WYou may use the back of this page to provide additional well construction info
- construction,only 1 GW-1 isneeded• Indicate TOTAL (add See Over'inRF�arfcsBi)Youmayalsoattachaddilioml.pagesifriooessazy
dolled:
24.SUBMITTAL INISTRUCTIONS.
. •9.Total well depth below land surface: ' :Z Z" • n
For mdtlpkwellr/rrrdldepthr/jd(Bgorr(Qmnp�g�00'tard2®IOp) ( ) u
(aJ Submit'tbis GW l wit)rin 30 days of well completion per the following: •
30.Static Crater level below top of rising: „• 24a. For All Welts: Orig�al foam to Division of Water Resources (DWR),
•
1Jvaterlevel Is above rsuhra jrrc/�-+� ' •
( ) Information Processing Uait;1617 MSC,Raleigh,NC 27699-1617 •
1L Borehole diameter: Cp �� {�, • • 246.For Injection Wells:Copyto
•
� I ) DWR,Underground injection Control(lUC)
Program,1636MSC,Raley h NC•27699-1636' •
• 12.Welk constriction method: /\ Ij tJl _ ,;
(ia cage;sohry,cable,direct push,etc) i 24c.For Water Supply an pen-Loop Geothermal Ratan Wells:Co to the
•
county environmental health Department of the county where installed
• FOR WATER SUPPLY WELLS ONLY:
-. 24d.For Water Wells producing g'over 100,000 GPD:Copy to DWR,CCPCUA
132.Yield(gpni) • /'2.—- •.Method of test: at.... Permit��m;1611 MSC, rgh,NC 27699-1611
I� tr
13b.Disinfection type: rk�-1- • Limonnt: /0 sec . •
Form GW 1 �asthCa Do]ioa epasenentofEavimameatal Quality-Divis ion otWaterResomees '
• Revised s s-sola
• 11I