GW1--01072_Well Construction - GW1_20240212

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'WELL •
•CONS ,
TRUCTIO EECO (OW--1) For Internal Use Only: C
1.Well octotgraiqufa o ., •
•. h i
•
Y t ti
weuce or 14:WATER ZONES p a : •
FROM TO DESCRIPTION
7—A- /0 0 ft.. )0 p ft. i V7,
NC Well Contractor Certi€catioaN f!
1 , ' .,��,_ -
IS.OUTER CASING(for mufti-Cased wells)OR LINER(Dap noble)
\��' C t"i /Brie'. - FROM TO . TnCIOlISS , MATERIAL •
_
I DIAMETER..
CompaayName •
r- (/ t tt' f I H �� 1 i°' I
2.Well Construction Permit#: 3 q•1X.. Y 1 16'I ERCASWG OR TUBIN ermal closed-loop)
Girl all applicable well eonrtnta/on FROM TO THICKNESS MATERIAL
panda n e.WC.Cotmy,Slate,Variance.ety tt 30 s
3:,Well Use(check well use): P ��
Water Supply Well: ft G it , ' _
.17.SCREEN B 6 1 a
°Agticultaral p cipaUPublic FROM it TO it. DIAM rxR SLOT SIZE THICKNESS MATERIAL
°Geothermal($eating/Cool ng supply) r ential waters _ � I ,
'4 Supply(single) �
OlndustrieVCommercial R 11 io'
° dentin'Vflater supply(shared)
• °lnitnition --- - • Is.GROUT 1 '
°Wells>100,000GFD = FROM To r ft. 7—ti .c LACfA�NYMLIBOD&AMOUNT
-
Non-Water Supply Well: -
• OMonitoriag ORecov v ft T tl G k lil r'� f
• Injection Well: ,.. •
f��D '/x Ft / f �l
• • ' °Aquifer Recharge' • °GmundwaterRemediation •
ft. !ti
l]Aquifer Storage and Rtxovery °SalhtityBatrier : 19•SAND/GRAVELPACK(fIppliable) . • -
°AquiferTest FROM TO MIl !. 'eL n�LAcsntz{NrMEisoD
bStormwdterDTainage ft: ft
°Experimental Technology - °Subsidence Contra' ' u '
tt ft. �
• °Geothermal(Closed Loop) °Tracer 11
°Geothermal(Heating/Cooling 0Otht'a• 20,DRILLING LOG(attach additional sbeeb if aecoaar')
FROM TO • DLScorn. ON War,kuda
(explain under#21 Remadrs) it.
� e+a,suUnek type,pain size,cto)4.Date Well(s)Completed:�r Well DM ft
5a.well Location: 1 �)ay s M t ads w✓:
I . J ft.•".e✓ 4%i Prct e, • ft. 'sc 11 I'.I i2/ _S c—
• Factlity/OwnerNaure . , e Facility MO(if applicable) ft
•
P BaIA ry` • l U102 ul) C�� ;•� 1 I � , ' r't► ,lI- i: • ,
bysi d ess,CCity,and rip
ft
( '`w "q ►` •
21.RElurARxsi d . 1' r 1-13 .1 G 20e4
County tJ PaeelIdentification No.(PIN) I
lstisttutW 4ra'zo[r:Ita Watt'
5b.Latitude and longitude in degrees/minutesfseconds or decimal degrees:
• (ifwell field.oat Lt/long is sufficient)
1'
lJ 2,CJ I a N gt l :, I,i:.
:y Z..�-z
6.Is(are)the well(s): [ ermaaent or. .°Temporary .2-7 ql D Signature atraeior -
V • _ Dam
7.Is this a repair to an existing well:. °Yes or No'. 1 ANCAC 02C:o 00 or ISA 02C.0200 ads rind krebycatfAhat Weft (were)
constructed tn aced' w th
Jfthts Is arepatr,fill era'brown well eo»rnueion hfotntaton the nature o the of this record hat been Cpnrwaion Standards and that a copy
'repair corder i2J remark;seaton or on the back ofth►rfonn f Provided to emit owner
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
• - - construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over!in Remarks Box You may also attach additional pages ifnecessary.
drilled:
2-I)) ' 24.SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: `
For multiple wells list all depth;/fdIfferent(=ample-3@200. 2@1 (ft) Submit this GW-1 within 30 d�ya of well completion per the following
10.Static water level below top of easier �' ; (ft) 24a. For All Wells: Original oIm;to Division of Water Resources (DWR),' , ,
'twofer levelIs above caring rue'+- ` / Information Processing Unit,16 7 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. /0 (m,) 246.For Injection Wells:Copy ! ,
1r Program,1636 MSC,Ralei N'tol D9'Und o Injection Control(NC)
12.Welk construction method: " (RD f d / B� 27699-1636
(i.e. 0 i�
"um ent ry,cable,dneupusb,etc) 24e.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the •
county environmental health department of the county where installed
• FOR WATER SUPPLY WELLS ONLY:
' '., 24d.For Water Wells produci over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Permit Program,1611 MS Rai rgh,NC 27699-1611
Method of test; ��.1/ C
yt
13b.Disinfection type: .l+T' 1- Amount: ' 2 41. ,
•
North Caroler;D • •
'
Form OW-1
Department ofFmuonmeatal Quality Division of WaterReaouroee _,