GW1--01965_Well Construction - GW1_20240322

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WELL CONSTRUCTION RECO .•(GW=11 • • For internal Use Only: I.: • ..
1.Well Con nlnfermatlon: e
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14.WATER ZONES - !..
Well Contract FROM TO • DEBCRIPITON
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.......•_ 5 9.7 - A ' •.. . too n n• &go. 1 I .
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NC Well Contractor Certification N er 15;OUTER CASINO(for multi-eased wells OR LINER(Ifap tteeble)' •
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J FROM . TO .n DUMrrzlt THICKNESS MATERIAL - ,
Company Name • n I: I .•_ Ia.�
�j • 16.INNER CASING OR TUBING(geothermal rioted-loop)
2.Well Construction Permi•
t'►!: I O PROM TO DIAMETER TEICImnns- MATERIAL
List all applicable weii construction penults(le.VIC.County,Stab '' n ft.etc) 1 • 55 f fpf in. /�ar9 a.I V • • '
3.Well Use(checkwell rise): • . ft. . • ft. l h.
isi, .in. •
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Water Supply Well: 47.SCREEN I,
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PROM TO. DIAMETER SLOT8IZE •THICKNESS MATERIAL• °Agricultural. Mumcipol/Publia.• • ft . ' ft. in. -
°Geothermal(Heating/Cooling B Supply) upp y(single)
(H •ting/Coolin Su 1 wrdential Water S 1
n n i 1.
OlndustriaUCommercial °Residential'Water Supply(alined) '
1s.GROUT
Ohrigatio1 . °Wells>100.000•OPD `• PROMy� . TO . MATERIAL ' IMPIAC1MINT METHOD&AMOUNT
Non-Water Supply Well: - -V .n DI IL --Nek k. n.,i1r ef e '
°Monitoring °Recov�; " n s
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N.
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Injection Well: •
, ��rT n^ �-+-�,�1
ft. n
°AquiferRexhargei °GroundwaterRemediatinn 1
°Aquifer Storage and Recovery . OSelinity Berner rx 8tlNID1GR0M �VELPACK(If epplluble)MATERIAL EMPLAcramtTMEIHOD •
°Aquifer Test, \* • °Stenmwater Drainage ' • h. IL 1t I I
• °Experimental Teclmology / °Subsidence Control ' . n 1t •
EGeotheimal(Closed Loop) t °Tracer I
I0.DRILLING LOG(attach additional sheets II necessary)
Geothermal(Ileating/Cooling Return)• ❑Other(explain under N21 Remarks) PROM . To DsscRHnTON• tc.l.r,i.rr■m;sell/reek tree.grate size, )
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. ft. ft. •
4.Date Well(s)Completed:.3'Y Zy Well D)# • n •
ft.
•5e.Weil Location:•
ft. n
Mab1L Su .al'
R. n t t•
Facility/OnmerN.me . ' 'r• -.•.. 1i • 4
Feoi�li IDII(if applicable) R n i
4-2 I -. 6rbsh•, Nl•1,,.. Y.. Ic fie, --n n .I 1a 2, v 2021
• Pl4sical Address,City,end Zip ft. 4 1t <^ ? ^z
-r I trgCri a S.i1 :.:5:514n2 Urck
UVIti/• .' • ; . 11.REMARKS/ l 1 I iS�}v �'
. County '; Piecel Identification No.(PIN) • : i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one fat long is sufficient) 22.Certiilc
' Star. 5 ' I q " N / -•
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6.Is(are)the well(s): 4rmanent• or °Temporary ' . I /r5V I 8igoedme of e Coc6actor' Date
By signing this form,Iherbycertify lha the wells)was(were)corutrueted In accordance with
, 7.Is this a repair to an existing well: °Yes or. )(No• , . ISANCAC 02C:NOD aell1 NCAC 02C.0200 Well Cpiutnnction Standards and that a copy
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.If this Ira repair,fill out Anown well construction Information and eipfain the nature tithe of this record has been provided to darn owner.
'repair under ill remarks section or on the back of ski form. . .
23.Site diagram or additional well details: • '
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the acme . 'You may use the back of this page TO provide'additional well construction info
• construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells • (add'See OW in RtniarkS Box).You also attach additional
''drilled• : �'4 may• pages ifnexeasary,
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24.SUBMTITAL INSTRUCTIONS .•
9.Total well depth below land surface: 6 . B •
Far multiple wills list all depths tfdlfferenl earraniple-3(a1700'and 24100) • ( ) Snlinilt this OW-1 within 30.dly' of will completion per the following:
: 10,Static water level below top ofcasing:-•• •(a b I . 24i._For All Wells: Original:folml to Division of Water Resources (DWR),•
Ifwnter level Is above casing;use"II+"I . ,. { . InfcrmaIon Processing Uri,1617l MSC,Raleigh,NC 27699-1617 • ,
11.Borehole diameter: •LP/ .(In.) r • 24b.For Injection Wells:Copy fo DWR,Underground injection Control(IUC)
� /; Program,1636 MSC,Raleigh,NCI27699.1636
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12.Welt construction method: • •' 0'.1e311. _ (Jl�h -. I I{ ,
(i.e.auger,rotary,cable,direct push,etc.) 1 24c..For Water Supply and O"pen'Loop GeotberniaRYeturn Wells:Copy to the
county cnvironmente I health department of the county where installed
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• FOR WATER SUPPLY,WELLS ONLY; • t
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.24d.For Water Wells proddd ing,`over,100 000.GPDE Co(iyto DWR,CCPCUA
13a:Yield(gym) d • Method of teat: Permit Program,1611 MSC,Raleigh,NC 27699-1611 ••
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. • .• 13b.Disinfection type: . ( •1'I4 Amount / t • W. " i
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