GW1--01011_Well Construction - GW1_20240208

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• WELL CONS y:UGTION EEC
• , .(GW.1) For Internal Use Only: • ,
1.Well Contractor. e
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•14.WATER ZONES 1 • 8 •
wenCoahaotorName PROM TO 'DESCRIPTION
'•5�7 'op n' 8W ft.', g. •
NC w ' tractor Certification Number n
15.OUTER CASING(ror n,ulti-cased well OR LINER(Hay limbic)
. �/N/ 7 - . PROM.. TO . DIAMETER TRIMNESS MATERIAL
ft.Company MO
1 In.�
16.1NNER CASWG OR TUBING We doied loop)
2.Well Construction Permit 11: •/ 7 a •
PROM TO DIAMlrER sync Rasa MATERIAL List all applicable well construction permits(i.e.WC,County,Stare.Variance.era) n s It In. .
3.Well Use(check well use): . . ft. R I
- • • Water Supply Well: • • :at SCREEN l •
• OA cultural PROM TO DIAMETER SLOT SIZE THICKNESS• MATERIAL'OMtmicipal/Public y
.°Geothermal(Heating/Cooling.Supply) idential Water S sine n • n I: _B In'
uPP1Y( 81)
OIndustriallCommercial n n p tn.'
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O idential'Water Supply(shared) 1a.GROUT •
°�igatio� OWeus>100,000 GPD ' . PROM TO aEA
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Non-Water Supply Well:- EMPLACEMENT METHOD AAMOUNr
°Monitoring °Recovery 2 _� a�'j'T.e'r s'x Air
Injection Well: •
ft. Ri IR pax j d
•• OAquiferRecharge °GroundwaterRemediation - x• n •
OAqui&r Storage and Recovery OSaI gnity Barrier•
19.SAND/GRAVELPACK(I pplimble) • • •
PROM I TO I MATERIAL )NIILACEMEIITMEIBOD
11°Aquifer Test , L- OStomnwater Drainage ' ft. n
°Experimental Technology• °Subsidence Control ' _ n: .R' A ,
• °Geotitermt!l(Claied Loop) °Tracer •20.DRILLING LOG(attach additional sheeb(rnecesaaq)
it:• OGeothermal'(Beating/CoolmgReturn) . °Other(explain under 021 Remarks) PROM n To •DERCRrt174N(cabs,iardaen,wfl tklrpe,crab,ria,ata)
• • - - 4.Date Well(s)Completed: 4"�S� 2t.j Well MN n n ,
S*.Welll,oeation: ft. fL' • "'l.rA r -
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( Yl o ma g :rt�l, • • ft. ft. �p
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c.
Facility/OeinerNeme Fam7ity IDa(ifapplieable) n ft, FEB• © O, .-lV k-Rd . Qq-es ..—:ft. n ' - ' lrl ei Pc •
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PhysicalAddteu,city and zip �) ft. ft. ••
11.REMARKS/
County • - • Panel Identification No.(PIN)
56:Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(ifwi ell/field,one leNong is sufficient) • •
G I 33 22.Certifi¢a' 1: - se474;04.0. ' .
SZ •N Ili a" 3l' . w
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6.Is(are)the well(s): !Armanent• or 1 °Temporary-- es eh l _Siaoahare,ofC • ell Centreetor - •
- -- Date
7.Isthisarepeirtoane:tistingwep: °Yea or • p.'. ' . B�'signing thlsfonn,l hereby cert(rlmtthewell(s)war(rer)conrhuctedin accordance with
_ / 13ANC4C 02C:0100 or7511 NC! 02C.0200 Well Conmpction Standards and that a copy
If this Is a repair fill out known well conrtnrcgon Information ad ain the nature ofthe ofthis record has been provided to a wen owner.
-'repair under 121 remarb section or on the back of this form. •
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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•
age to provide additional well construction info
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construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in R marks Box You may also attach additional pages if necessary.
drilled:
-�f/� ' 24.SUBMITT'AL-INSTRUCTIONS
9•Total well depth below land surface: (J rJ.V (n)
Formulaple wells list all Ards llideerenr(esample-441001 and1(e)100') Submit this GW-1 within 30:days of well completion per the following:
10.Static water level below top o;easimg: 3 d¢ 1• : (ft) 24a. For All Wells: Original f arm to Division of Water Resources
(twofer level►s above casing;use+- Information Processing Unit,16 T Raleigh,NC 27699-1617 � •)�
11.Borehole diameter. /� (in.) 24b.For Injection Wells:Cop to DOo
• Program,1636 MSC,Raleigh,',' Underground Trajection Control(IUC)
12.Welt construction method: • a f•a tty gh,' 27699-1636
(i e.auger,sotny,cable,directetc.) 'tatty _push, 24c.For Water Su 1 .and O n-Loa Geothermal Return Wells:Copy to the
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county envnronmen apartment o e county ern •
• • FOR WATER SUPPLY LIS ONLY: - tl
24d.For Water Wells producti¢over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of teak .. . Perot Program,1611 MSC;Raleigh,NC 27699-1611�:
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. ' . 13b.Disinfection type: 1 �7.,•. •. Amount: ••, 1�Y
.'Form OW-1 ,' c North Carolina ,Deputment oEFaviroamenhl(hetiw_n. .:___e..._. ..