GW1--01820_Well Construction - GW1_20240322

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W?LL CONSTRUCI'IO RECO (GW-1)
•For Internal Use Only: , -I..
' L Well c o • -- .
14.WATER ZONIZSS ( r l Wall Cones Namo FROM
. ' ' ''' •"'LF5 G 'TO • DESCRIMON
NC Well CootractorCeetifioationNumber ft. f4
15.OUTER CASING(for multi-eased wells OR THICKNESS
ap 6uble)
a ker`i •FROM . TO .
DTAMLrSR' MATIRIAi..
Compa'nyName i< tc I i."jO
2.Well CoastroctionPerm'f#: 1(J .� W •
16 DINER CASING OR TUBING(geothermal eloied-loop) . • -
FROM TO MAMMA,.
List all applicable wdl construction permits(t e.WC.Corm%,State,Variance,etc) f ft' T� MATiRL1L
4/i n ,S7/irk'" �r''�
3:Well Use(check well we): l ��l oil.—it /� j
ft. ft. 1' ,'a j
Water Supply Well: f ,
,17.SCREEN { ,
• l7Agieullural. OMuaicipaiUPublkC • FROM •
TO DIAMETER I SLOTSIzE •THICKNESSMATERIAL
' - DGeothermaad(Heating/Cooling Su ft. I. R _ is
Supply); rdeutiel Water Supply(single) : it ft Ls:'I
. t OlndustriaYCommerciel E]Residential'Water Supply s h
uPP Y.O la.GROUT OLrigatio(t • OWedls>100,000 GPD '~ • FROM TO : '
Non-Water Supply Well: ... A EMPL�ACEMENTMslaoD&AMOUN•T
OMooitoring Oltecovery �r-1 1 ft N�' :�(.d
Injection Well: .. ... ft'
�r vL t
O uiferRec OGroundwaterRemediation . �. .
g
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OAquifer Storage and Recovery ,OSalinity Barrier. • - 19.• SAPIDlGRAVIf L PACK(N■ptlJable)
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FROM ' TO .
OAquiferTest•. ti
OStormwater e a fc !t fAC�rlMrraoa
Drainage i 1
OExperimentel Technology OSubsidenca Control I .
fc . ' fp. '- I ;1'
OGeothennal(Closed Loop) 1,1. Diaper . '� -
'20.DRILLING LOG(attach additional sheets if necessary) ,
DGeothermal(Heating/CaolingRehun) °Other(explain under#21 Remarks) Fin.%' TO - • DPSCR1I'11ON(calm,aardaeo,+.Wrackerpe,patesa'm,eta.)
4.Date Well(s)Completed: 3-5-L•/ fc' . _ fc -I' i
Well ID# • ft' ft
• I - a.4 t e *4' Nk1 L ii.; a R. '‘ 04) • ft
Facrlity/OwncrNemo
Factii Mil(ifeppliable) ft R i :.. f.. a'1 6
Mtn: , �A i �d ,'iz ; ,. _k._- ` "
Pbgaial Addcaa,City.and Zip - ft. .ft M/ l 2. 2:2024
County • 'Plural I Pt,:,
Identification �' FrliZ;e.'C rtiir .. .,.Y*v:.�fir,
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(ifs e1d,one odes is aufficieni) //;; —
b l .2 "N VV ^ 5? s .5 ! • W } .,
6.Is(are)the wll(s): permanent• or OTemporary 0
Sit;na4trr of • •fall Ca,u.ctor `� rZ
r\ � lIpato
7.Ist isarepairtoanexistingwell: • OYes or gat+l8nlnyfhlrjerm,lherebyeerOiliotdrdwell(ilwar(were)canrurreledInaccaonicewlp ,
NI • . . !SANCdC 02C:0100 at732IHCdC 02C.0200 Well Cpiutrttedon Slaedards and that a copy
IfMIris arepak fill out known well corutma=learetadan the tram rib, ofth4 record has hen provlded to the am
en wns'•repoliraderONN rema b section or on the backafthi,form. -
23.Site diagram or idditionil.well details: -
8.For GeoprobelDPT or dosed-Loop Geothermal Wells having the same " You may use the'back of this page to provide additional well conchuction info '
construction,only 1 GW 1 is neede�Tndicato TOTAL NUMBER of wells ' (add'See Over in REniarks Box):You may,also attach additional pages ifnecessaiy' .
' drilled: .
f 24.SUBMITTAL INSTRIIONS ;; ,
9.Total well depth below land surface: U
Formultiplews1ts list alld ( `, (i<) Strl'raltthisGW;1within30daysofwellcompletionperthefollowin
+lBerait warn 4-3 'md2(�100�' g
10.Static water level below top of casing:- G 1) ft). 241...For All Wells: Original form to;Division of Water Resources (DWR), '.
ljwarcr level tr above eariny itre"+' ( t Infcimatitin Piocessiag Unit,1617 MSC,Raleigh,NC 27699-1617 •
11.Borehole diameter. •• •� (/� , ,(in.• ) 24b.For Iojectioa Wells:Co Df }
PY to WLZ,Underground Injection Control(I1lC)
• Program,1636 MSC,Raleigh,NC 27699-1636'•
12.Well constructionmethod: • P b F. i,:., ,4 •
(ia auger,rotary,cable,desert push,ore) For Water Supply and Open-Loop Geothcrmaletusn Wells:Copy to the .
county environmental health department of the county where installed FOR WATER SUPPLY WELLS ONLY:
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24d.For Water Wells prodeido¢over.100 000 GPD:COPY to DWR,CCPCUA 13a.Yield(gpm) 5 Method of test: -(i(fl.%1/ • Permit Program,1611 MSC,Raleigh,NC27�99-16i 1 "
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13b.Disinfection type • ' 1� 6'.‘..':."Ainonnt: 0
Farmow i •
' —, North Carolina. --- D6■tmteotoff-4ritoame1la1 _
maionofWatarltwouraa j n_._.
R�uY D'
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