GW1--01817_Well Construction - GW1_20240322

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WELL CONSTRUCTION RECO Y� •
(GW-11 For Internal Use Only: h
• 1.Well Contra.,� • ormatiou:. . • -•--
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14 WATER ZONES p !
Well ContractorN • PROM 'TO • DESCRIPTION
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` 5qi A 2ovlc .52, ft , 1 1
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NC WellConiractorCottlScaponNumber ft ft: I 1 '
15.OUTER CASING(for multi-eared n elb OR LINER(if ap licable)
.. „ ' •,i CIT.L 6 AI; h) 'FROM . TO . DIAMETER .. THICKNESS g MATERIAL' ' •
Company Name' • n I ft. I _I ` In I I , • ,
16.2.Well ConstructionPetmit'#: v (p D Z,y �o�ER'CASR G OR TUBING it ernial closed-loon) -
• List all appllcabk well construction porn its(1,e.WC,Coun%,Slate,Variance.etcJ ! • *' .ftM TO. /e THICKNESS MATERIAL
�i3' ft 1° 7hlcsti '
3.Well Use(check well tise): - R - ft i in.
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Water Supply Well: ,)7.SCREEN •
• °Agricultural, "'OMunicipalPublic.. PROM TO DIAMETER, sLOTS1ZE •THiCRNESa MATERIAL
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°Geothermal(Heating/Cooling Supply) [ es'idential Water Supply(single) . •
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Olndustna]/Cammercial ft ft id'
OResidential•Water Supply( ) 1' ' •
OLri 40 18.GROUT 1 .
ga n °Wells>100,000 GPD '' • FROM TO MATERIAL 1t11IPLACEMENiMEfHODdcAMOUNr
Non-Water Supply Well: ' • v
OMorytoring ° Yuy Q tt Z aA (
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Injection Well: , fc IQ.1'7%Y�,hr4 - r(,a.r ✓I-
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DAquiferRecherge OGroundwaterRemediation ft ft'
' Harries 19-SANDIGRAVIILPACK(N'app1cable) ' . ' • : • • , •
OAquifrStarageandRecoYery °Sal
O uiferTest. %\.
Y FaoM To ' ' MATERIAL EMPLACEMENT METHOD
OStonnwaterDrainage ' ft • ft
()Experimental Technology °Subsidence Contrtih • •
Q
ft . '
• . I7Geothennal(Closed Loop) !. . °Tracer • i f '
•zo.DRILLING LOG(attach addidorial ibee6 if necessary)
°Geothermal(Eeating/CoolingRetum) °Other(explainunder#21Remarlra) FROMTo DESCRieIIQNfubr,i.,d.ea,,umncehndmi..la<,ae)
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R ' ft ; } . '
• 4.Date Well(s)Completed: 3'/Z'2-A-/ Well ID# tt rt
•Sa.Well Location: • „('R. p (�C t prl•C . Y I�IJL(/t• R ft /ft. I
Facility/Owner Mine' Facility Mil(if applicable) ft . - ft•
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Physical Addicts,City,and Zip ' ' • g �a' .�. "x` , � F
th.
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G( ��c,,�t�. - 21.REhMARKS!� • c. nR
Parcel Identification n_(PIN) ;! ex:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ;1
(if well geld,one lat/long is sufficient) - ' F""`r'
��r. . 13 r r 3„ N A , , , �� , 22.Cer(ifie`ta ) •
(� 5 w � :1 • 3- ii -2. .
6.Is(are)the well(s):Armanent or °Temporary lOiErU ) Sigushun of elf Wed Conk actor I I D,te
Byslgningthlsform,'hereby certlfythat thuirel(s)was(were)con:uuciedinaeeordancewith
7.Is this a repair to an existing well: °Yes or, o. 1SANC(C 02C:0I00 or25.1 NC.tC 0IC•0200 We/1 Cpintruction Standards and that a copy,
!phis isa repair,fill out brown well construction Information and ta�/ain the nature of the of 10 record has beenprovlded io the wail Omen .
'•repair under 121 remarks section or on the back of this form.
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•'' 23.Site diagram or additional well details: -
8.For Geoprabe/DPT or Closed-Loop Geothermal Wells having the same • • You may use the back of this page to•provide additional well construction info •construction,only 1 GW 1 is neededjndieato TOTAL NUMBER of wells (add'See Over'in Rt narks Box).You may also attach additional pages ifnecessary.•. •drilled:
C�Q 24.SUBb1I7`TALJNSTRULtIONS i••• •
9.Total well depth below land surface: ' J • (ft.) • • ,''•• :.
For multiple wells list all depths if different(example-g()7000'caul ( 100') Submit this OW-1 within 30 days ofwell completion per the following:
10.Static water level below top of casing: (� (� •
{ft)'•2di:.For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level Is above earin&sus//e"��(/ Infcrmatidn Processing Unit,1617 MSC,Raleigh,NC 27699-1617 ••
11.Borehole diameter.. lJ�O • 24b.For Infection Wells: fo DWR,Copy Underground Injection Control(lUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well•construction method: •• j � AY."'• i
(ere:auger,rotary,rabbi,directpush,etc) 24c.,For Water Supply and Open-Loop•GeotherniallYetui iWells:'Copy to the
county environmental health department of the county where installed • •
FOR WATER SUPPLY WELLS ONLY: • • •
11 • 24d.For Water Wells proddcing over.100 000.GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 1 Method of test; !A.A/li • Pemrit Program,1611 MSC,RalwghiNC27�99-1611; • yti
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13b.Disinfection type: l � Ainouot: ! •Y
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