GW1--00602_Well Construction - GW1_20240118

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WELL CONSTRUCfON DECO' .(GW-1), . : •For Internal Use Only: •? - . . '
1.'Well Contractor.Information: `_
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J�- tn{qq�r •
•u.WATER ZONIS i. '
Well ContnetorName : J PROM TO DISQUP ION
. . ft. yam 1
. . • - ' �353_-A �u
Ms Well Contractor CertificationNumber
y� 15.OUTER CASING(for mol �ons O ap finable)
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/lPWrr n �rotktrS fitG . FROM D MATERIAL
Company Name O n JTO .
lc** I 1.&Vv in'� T krC.L. pve_- •
•• 2.Well Coustrnetion Permit#: �fj���/ . 16.'INP1ER CASING OR TUBING(teotber,al elated loip) ,
• PROM TO ' •f MMX'rZR THICIOUss MAMUAL List all applicable well construction penrdis(Le.WC Corny,Slate,Variance,eta) - R. n• IN.
3.Well Use(check well use): _ . . n
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Water Supply Well: • - • �7.SCREEN i
°Agricultural . OMuaici PROM . :TO DLAMI T R SLOT SIZE utr aM58 MATERIAL pnl/Public; ft n _ In -
OGeothermel(Heating/Cooling Supply) esidentiel Water Supply(single)
OlndustriallCommercial n n in'
OResidential'WaterSupP1Y(shoed) le. . .
011rigatioq - - --.. '_ - - i- ' _„__ - -
°Wells>100,000 GPD- �' '� - PROM TO . nrA•ISRTAL taditucrau,NrMETHOD a,AMOUNI Non-Water Supply Well: G n a3 fL n' ,F a� P�—
°Monitoring ', • ORecovery R n G
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' Injection Well: •
• • 'OAquiferRecharge , . _ . ' ❑GroundwaterRemediation n, ft.
°AquiferStoragei and Recovery °SdinityBertier 19..SAND/GRAVEL PACK(if bpplicable) •• • . •
PROM TO • MATERIAL.. =MPIAC►4ENr amnion OAquiferTest °StormwaterDraimge • ' n
°BxpetimentalTechnology ' OSubsidence • • 1:Control n • n .
°Geotheamal(Closed Loop) OTracer �r
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• 10.DRILLING LOG(attach addidoeal sheets if necessary) • • -
OGeotherma] eatinFROM • TO DI5CR1lr14N(Me rbsriaeu,nNnekype,paia size.ec)
(H g/Cooling Return) °Othtx(explain under#21 Remarks)
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4.Date Well(s)Completed ' /-//-47 Well ID# 3 710 7,,•4 .- ft. •ft •.
Si.Well Location: u I
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.' �e -t'S(1.2a4• 1�i 1. 1st ' ' n•
ft. • 0 ��r'r 'c'
Faeili Owner Name P Faetlty IDr(if applicable). • • n R �.
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u 4csnav eprirI- r{sf Dupr/adk.Lc Iu. 1 s �iA '''ft. ft. • p'i '` •S 2024
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. Physical Address City,and Zip , - ��•�Gi ft. tt lIh`e`n°;P£q!"1+Dr
( ii Sh t Dia 3?SDOa Q Ii.REMARItS
County Parcel Identification No.(PIN) 1. ,
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56.Latitude and longitude in degrees/minntes/aeconds or decimal degrees: s li/� t
(if Well Sold,one lot/long is sufficient)
22. +r1"'
3�oa Is- �h t r C t i• aCertj on_
NII aa 7 W.
6.Li(are)the well(s): permanent or °Temp dry . Si s Well Con r
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Date
7.Is this a re Pair to an .Sys►gning th form,I bersby certi hat the well/J '
P existing well: • Oyes or to• (JvastSrrn,tton&rndar&andacr o
!fats I,ra r • !Phis
MAC iha:been
pro idediA w! owner.0200 Well Cprar►nrcNon Standards and that a copy
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re out woranrt the back this/a m. and oplaM the nature of the .ojd+l+ncardhat bernprovlded to r mU
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'repair under r111 remark:cation or an baekojrhbjaini
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 this
• . construction,only 1 OW I is needed. Indicate TOTAL NUMBER of wells (add'See Over'is R�arb Box You to provide attadach
a di well pages i nec info
drilled: additiowl pages ifnecrssary. •
▪ 24.SUBMITTAL INSTRU OPTS
9.Total well depth below land surface: e.24' 1 IL •
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Formultlfleweltrltsrdl/dspthglfd/�snm(uomplr_g�7p0•and 7(a3100)• ( ) Submit thisGW-lwithin30d�yiofwellcompletionperthefollowing
10.Static water Level below top of casing. '(} ▪ (�� •24a. For All•Wells: Original 4
' - IfwaterlevelIsaboveearinguse'+" Information Processing Unit,16 7fMSC Raleigh,NC2 6on of 99'l ounces (Dgtg).'
.11.Borehole diameter: G is' 'I
fin.). 246.For Injection Wells. to DWR,Underground Injection Control(RUC)
12.Well eonstruetion method: � t Q r !regnim,1636 MSC,Raleigh, 27699-1636 - .
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(i.e.mac;eoiuy,cable,direct push,eta) .. '2�Fo Water Sou 1 and O en-Loa Geothermal Return Wells:Copy to the` '
• FOR WATER SUPPLY WELLS ONLY: : ' •
exit a cotmty where
• 24d.•For Water Wells prodddni,over 106,000 GPD:Cop to D •13a.Yield(gpm). Method of test: qi r • • Permit Progrant,1611 MSC,Raleigh,NC 27699-1611 CCPCUA
13b.Disinfection type: • (+r •.' Amount: . vL • '
Form OW-1 -
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. - . North Carofma Depubnent ofF.r..:m.........i n.-e..- .,•__•_•• _-_