GW1--01010_Well Construction - GW1_20240208

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. • .WELL CONSTRUCTION RECO .' (GW-1), • . • For Internal Use Only:, ; • • • •-r••
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1:Well CON •Informatien: a' ' . .' ••. • . . •
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• . • ..• •14.WATER ZONIS • It• " • .
• ' . • PROM TO DESCRIPTION .Well Ccretractor . • • .
. 154°ft-. A" ft. t : . ' . •. • .
' ' • .. • L4-..5 q-7-,11 . ft. ft.
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.NC Well Centraetor Certification Num •ber .•.
IS.OUTER CASING(for multi-cased wells)OR LINER(if an Humble) ..,. . •
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iltwrilaAt,637m. • . . .•. . '•PROM
ft. TO . ft. TAM RITA_ . THIQWESS MATERIAL ‘..
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COmpsny Name . • •
' •. 16.'INNERCASING OR TURING(geothermal cloied-locin) . • • ' ,
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• 2.Well Construction Permit#: (-1-i.,•, V , , , •_ . • PROM TO TRAMETER. THICKNESS MATERIAL
. ' Litt all applicable well iteutruetton permits(1.e.UIC Como%Static Variance.ale) ÷'1 fL ,55 -ft' 15/4011. p il...• .
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3.Well Use(cheek well use): - ' • . • rt.
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47.SCREEN 1 1' • • • .
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Water SupPly Well: • • . . • -
PROM ' TO DIAMICI'IR SLOT SIZE nucrairss• awn:1%1AL .
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. • ['Agricultural --• . - .. '0/4unicipallPublio • ' . ft. ft. ...1.. in. .. .
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' 0Geothennal(Heating/Cooling Supply) ...ElkdidentielWater Supply(single) fL IL" .•1 In. . . .
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OlndustriellCommercial . • OResidential Water Supply(Shared) 18.GROUT • ' •11. .. . -
°Irrigation . - '..... OWells>'100,000 GPD .. • . PROM TO . - MA 4* EMPIACIATENTMEIROD&AMOUNT
Non-Water Supply Well: " - 0 tt., 3 ji ft. if ern" M I yie4
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• °Monitoring • 6' ['Recovery . . IL i ft. _IA
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, . ur iP . • .I• .• Injection Well: .6 : • ' • rt. . Ifsi )Gil,
ft.. . 1
: . . ' • °Aquifer Recharge • .- - .
' ['Groundwater Remediatiou
19.SAND/GRAVEL PACK(ll'hoplicable) • • • . • •
- • °Aquifer Storage and Reeovety 6 . °Salinity Beirier • '• 7 PROM TO T MATERIAL virLicaktorr MEDIOD
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a • . rt. It. •... 11:. ' . .,
. . .['Aquifer Test.: ' • ' : OStormwater Drainage. . •- . . . .
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. - . 1 11; , • . • . • •
• . '. ' OEXperimental Technology . : °Subsidence Control • ft. ft.
. . ,• CIGeo thennal(Closed Loop) ''"'"•1 • .' ••°Tracer • . - 20.DRILLING LOG(attach additional sheeb irnecessirA . .
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°Geothermal(Heating/Cooling Return) ' °Other(exPlain under#21 Remarks) PROM it., TO - ., DEU1.CRIPTI ON(color,Inirdoess,sellinekl7pe,gran rise,ele.)
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ft. , • •fL • ,,.f. . ". .
.. . • • 4.Date Well(s)Completed Well 1-4, Nviumi •• • • .
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' .52.Well Location:
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' "' •- • -. .-. A II-a,ii. Lop ,-) - . . . ft. ft. FEB 0 8 2021 • -, - • .• Feeility/Owner Nome • • • Facility IDE(if applicable) , • ft. - H.. ,
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. . i‘fte..ire t. ell 0 7. Dci i evj • Rd • • - .• ft, ..'1 . .. . inieirfAge.;IP:recgosirli u4.
;. . . • Physical Addwss,.City.and Zip : • 1...V;do 4..,,,,. g raj, KA• It.
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. . .2 atiLt 1 C/:a< . . ..- 0 • •. • 21.REMARKS/•. - -
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. .- ..County' Parcel Identification No.(PIN) • . . ,
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5b.Latitude and,longitude in degrees/minutes/seconds or decimal degrees: .6 . . .• • ..
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22.Cer•" -14- •:. :•.,_ -l• •, : • ., ' . • • .
• • - • 310 s - 30. 3 q aN•• 81 ' • .5 .- / q , . .
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6.Is(are) Swat=6,f -•i...::."ell Contmet .or • Date -
the well(s): 9ikrmanetit or OTemperarY. . /r6/0 .•.•,..
40 signing thirfonn,I htfeby eertlfylhat theliell(r)was(were)eenstructetOn aceoivkinee with •
. '7.Is•this a repair to an existing well: Dyes or 1 o• • •
.019, ISA NCAC 02C0100 oe1.111 NCI 02C.0200 Well ColutrFction Standard,and that a copy
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phis I i et repair,fill out known well construction Infonnagon and !atm the eaters ern.e . ofthis record has beat provfded to 4e well owner. , ,_ •
' •. . 'repair under N21 renter*,section or en the bock of this form. • • •
23.Site diagram or.udditional ell details: • ,
8.For Geoprohe/DPT or Closed-Loop Geothermal Wells having the same • You may use the back of this age to provide additional well construction info
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,(add'See Oyer'in Reniarict BOx You may also attach additional pages if necessary:.
• • . construction,only 1 GW-1 is needed. Whittle TOTAL NUMBER of wells• -.
drilled: • - •• - •_ . ,
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. •.'. , 24.SUBMITTAL INSTRUCTIONS . .
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' . . 9.Total Well depth below land surface: • 1- .40 i • . nu
. • f Submit this OW-1 within 30 4 ys of well completion per the following: .• ". '
FOr multi&wells litt all dwihs rcarerenr(example-3@.200'and 2g1.100)
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• . 10.Static water level below top okcasing. & (IL)
O . • 24a. For MI Wells: Orighialroan to-Divisioit',of Water Resources (DWR);•
. Information Pncessmg Unit,116 7 MSC,Raleigh,NC 27699-1617. • .. ._ _ .•
'twofer levels above eatIng,:ttie"+" . . '
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' - - , 11.Borehole diaineter: & Vt.. (i .) "• • - 24b.For Injecticin-Wells:Cop to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh, r 27699-1636
12..Welt construction method * IR o 1-a 4 • •ci....4 -i. . • _-. - • . -
' -• 24c.For Water 5unitly and.Otti n-Loop Geothermal Return Wells:COI*to the
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. •' (i.e.auger,rotuy,cable,died pink etc)- i 7 • county envuonmental health deprtment of the county where installed
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• FOR WATER SUPPLY WELLS O)ILY: . . '
24d.For Water Wells producing over 100,000 GPD:Copy to'DWII,CCPCUA
• •• .. Permit Program;1611 MSC,Raleigh,NC 27699 1611-. •
13a.Yield(gpm) 1 0 Method of tesb . a,.{.A..' • • - ' , , . , 1..1 '.. : . . , . • it ' . .
13b.Disinfection type: " l'i If l•-•_ know&--• '•2( ......,;- , .. . - . .. • ;•• . • . . . ,
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•" _ •Form OW-1 •. •• •'• • • . Wiwi).r.,....E.--n--..........-_.•••.___• • ...... ... • - . "