GW1--00003_Well Construction - GW1_20231218

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WELL CONSTRUCTION 1 E • �- -CO' (GW-11 • For Internal Use•Only:
• 1.Well Coatrae s -,ormatio 'a _
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I .0 ft II •
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Well Coatraitor •14•wATER zotufs )'8 .
PROM TO I.DESSQunaON ..
NC Well Cpatractor Certification N !G !< t 8
- o�,, IS.OUTER CASING(for>ti°IboaedMails OR LINERarap Geable) •
inibtrrnailit).
�" PROM' TO . �@ 11 ��.TffiaWkSS MATLiWL _
CompanyName . • R I
2 Well Const<uctioa Permit fir 6 ix
I6:iNINER CASING OR TUBING canal eloied-laip)
2. all Construction
well t+ . PROM TO. Tnmmo SS MATERIAL
applicable conrwaion'emits(.c WC.Cow*,Starr,Variance,sic) f I m 3( t<' @ S 71' id
3.Well Use(check well use): r �'1 Mh rL
• ft. @' is
Water Supply Well: 41.SCREEN i II- • .
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°Agn�q� OMtmicipal/public - PROM TO DIAMETERSLOT Sue THICKNESS` MATIPlAL
• ft. • ft. H (1 id
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°Geothermal(Heating/Cooling Supply) --B esidentiul Water Supply(single) "i `
DlndustriaUCommexcial it ft. @ N !�'
D idential Water Supply( �
❑Trrigatioti 1s GROUT 1.1.
DWells>100,000 GPD ' PROM • TO - .1ETATIAL II1QrAQA>Irr METHOD&AMOUNT•
Non-Water Supply Well: - • - .D f' 2 II
• DMonitoring • Recovery '@ tl l V i i�' Y
D @ Ail �.2
• ,1: `f. n
Lrjectioa Well:' •
Orr i a' P 0 e
°AqH1 0GroundwaterRemediation ft @
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DAgnifeCStoragearldRexaYery DSalulityBarrier 19.SAND/GRAVEL PACKerf ppbcable) • . . _
DAquiferTest PROM TO MitTERiAL • >u�1AC>a�trrMKsraoD •
DStormwaterDrainage ft R @ G
°Experimental Technology °Subsidence Contnif • ft. IL 6 II
• DGeotheamal(Closed Loop)' DTiacer
'20.DRILLING LOG(attachi G
(attach dditional abeam if necessary)
DGeothernal(Heating/Cooling Return) 0Otha(explain under#21 Remark) PROM ft. TO' Do ICRn uON(alar,baniaa4 Pan adc yrg era aim,etc
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' 4.Date Wells)Completed: /2—IS-Z3 Well INa m �,
Sa.*ell Location: - •
• l. . a � � , - n ,ris r;:.Far7►ty/ORae:Name Facility IIN(ttsPPlieable) t t111 .r.
I , , ,,�,
--ft.
ft ` Die� B ' 11(�, S ► Rd
Physical
21.REMARKS/ .,y.(,;-
County Parcel ldentiteationNo.(PIN) • . @ 1^^1•'
- 5b. .atitude and longitude in degrees/minutes/seconds or decimal degrees: @ G
(iffwell field,one lat/long is sufficient)
3(o • 1 d c36 N s W. 22.Certifier:' a _ .ti .)
•6.Is(are)the we ll s: 7 , _ /2- /3- Z3•
() 4rmanent' or DTemporary 3 !Q Sigosgaeof eellCantrriexor Dam
7.Is this a repair to an existing well: DYrS' or °.' _. Bj,signing dd.:form,lAerrbyea hat the ws!!(r)war Ogre)constructed ft oaadada cewlth
! I s bi 154NCAC 02C:0100 or754 NO# 02C.0200 Well Cluotruedon Standard and that a copy
j repair fill and known well construeHon information /ay the natter of die offs reeordhee beanprmgded to, a well owner-
•repair mrderf2l remarlr section oron the back ojthttform
23.Site diagram or additional 'ell details: •
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You'may use the back of thi, age to provide additional well construction info
• construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells (add'See Oven in Remark Bic You may also attach additional pages ifneoessary
drilled:
• 24.SUBMLTTALINSIRUCTtONS .
9•Total well depth below land surface: ( )
Amer wells lift all depda 1jdieent(csampk-3� and 2@.100) '• • Submit this GW-1 within 30 M Is of well completion - '
—7 It Y p per the following: ..
10.Static water level below top of easing•, l � ; (it) 24a. For All Wells: Original? I an to Division of Water Resources
ljwaterlevd tr above cnreny;nre/+1�� Information Processing Unit,16 ?MSC.,Raleigh,NC 27699-1617. • � )�•
11:Borehole diameter. LO (m.) . 246.For Injection Wells: t
_ Program,1636 MSC,Raleigh, to DVPR,Underground Injection Control(IITC)..
12.Well constrruction'method: : j Zo-�• — gb, 27699-1636
(i a auger;=otyy,cable;direct push,etc.) ` 224 For county Water Sup ly ar• ia Or en-L'oon Geothermal Return Wells:Copy to the '
• FOR WATER SUPPLY health department of the county where installed
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WF.rrcONLY: Y
' ^ 24d.For Water Wells prodd ng•oyer 100;000 GPI)Copy to DWR.CCPCUA
13a.Yield(gpm)•. ' Method of test: f ) , A• . Permltl?rogiam,1611 l+ZSC,'ItalFlg6,'NC27699-1611
« � h
13b.Disinfection e. Amount: !() •Lv . • .
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Form GW=1 North CamlmaD
epartment•
° ts1 Qutlih-Division of WatesR esoerea� Dom,..