GW1--01974_Well Construction - GW1_20240401

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WELL,C a ' UCTION • CO (GW--1) For Inte•• final Use Only:
1.Well Con..c . ,1r' ..i -_
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• • • • •14:WAT$RZONES . • 1' ,
Well Contractor Name :' PROM •TO DLSCRWr5ON
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ti q.?._A • /ov ft.' yea ft i
Nc Well ContrectarCOfie oaNumber to re•. I. I ,.
�•�� • _ • 15.OUTER CASING((or multi-cased yells OR LINER(if op Ruble)
y,��,,, L 1 •FROM I TO Lt D srrER'•' TDICIWLSS MATERIAL
CompatryNane �, - .R • .f6 .L - � .
2.Well Construction PermiEit: IS�' • 16.INNER CASING OR TUBING( R trend doled-loop) . ' . . . ., .
PROM TO T�CIQRSS MATERIAL
List all appllvblewell construction fernt;te F:via Cam%State,!Mane.%eta) .�I fe. y2/t E' :P
3.We11Use(check well use): • `• (-'
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_ Water Supply Well: : �7.SCREEN
• °Agricultural, . • 'OMuoicipol/Public• PROM To DIAMETER.'
sLorstrs •TAIC(WrSS MA7cRIAI
❑Geothermal ea re to iu
(H ting/CoolingSuPplY) . ldenttial Water Supply(single) ;
' OlndustrisUCommercial fc n In r
ORcsiden'.ial'Water Supply(shared)
Okrigahop '• lti.GROUT i � � �. '
°Wells>100,000 GPD '• FROM TO MATERIAL EMPLACPMEtTrMEIROD&AMOUNT
Non-Water Supply Well: . . • ft..• , / p
°Monitoring •• . . - Cl .ic N �' I V t r': .
Injection Wen:• • t itecovcry tt. rf e$Nit Wt� .r✓(
-' -0AquiferRecharge .. OGroundwaterRemediatior. tc
OAquifer Storage and RectiVery OSalitvtyBazrier 19.SAND/GRAVEL PACK(If applicable) . , - •
' OA uiferTest. '• PROM To MA -1'• ,1,' L+wL►C�nrrMttz$oD -
4 OStotmwaterDrainage ' • ft. ft. , ,
°Experimental Technology'.,. /: OSribsidende ,; .
Control
RGeolheralal(Closed Loop) lac °Tracer
20.DRILLING LOG(attach additional sheeb if necessary)
°Geothermal(Eieatinp/Cooling Return) - °Other(explain under#21 Remarks) OM TO DESCRIPTION fobs,batd.au,,.Wnek hen er m eau,arc) .
It: it,..
4.Date Wells)Completed 3 !•ZD Well ID# ' ' • . • ' ft •ft- ,
Se ellLocandn _^w . fe
(D'lc)d • D(.l h'f��t/Y)'1/ .. , • •' • '• 'ft
Fadiity/Owner Mite. ' Faettity Ink(if applicable) ft fe
Pffhynic'al Addre ,City,sad Zip 'ft t -
. Comely " ' .:. Pir_el I(entifi:atioalio.(PRI) Ir:i+3;, '1 C;1. .
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5b.Latitude and longitude in degrce.•hninutu/seconds or decimal degrees: G' � "' ' ' : "
(if well field,one lat/long is aui5eian)
N �. . W ••
,r _ 'p'' �
6.Is(are)the well(s): T ermanent ' or• °Temporary. i 2`...41
�I �I ' Signature' ell Contractor "t i Data ,
7.IsthlsarepuirtoaneaistingwelL• °Xes or No• ,•By signing thisfonn,I hereby cerl rhattheigell)was(wer)conitrueied/noceondmtuwith _
. __ .,If this lea repair,fill out brown well conrtrueton Information • sin the nature of the fthii record1har Ie0ninvi NCACe well2C ow200ner.
r. Cglulru;. 'Sfmidardr and that a copy
'repair under On remarfrsection or on the back of this form o I to Oie weU oirnar.
•• 23.SIte diagram or Additional well details:8.For Geoprobe/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 necdc4Indicato TOTAL.NUMBER of wells (add'Sec Caret mi'tt:Auks Box).Vou may also attach additional pages if necessary, ',;.'.
drilled:
'l� . " 24.SCIBIVITI`rAL INSTRUCtIONS '• '. •
9.Total well depth below land surface: . T�(.1 . ' (fe) . ' ' , 'Formultlple wells Bet dldepthr/fd�erenteceampie-3®200'and 2V005 . . . Subriiit this GW.1 within 30 diys of well completion per the following: ,
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10.Static water level below top of casing:' • •'d O {ft)• 24a. For All Wells: Original'form to'Division of Water
. ifwater levelly above easing)ire"+1 Information processing Un►t,1617 MSC Raleigh, Resotuces (DWR),'
'� ! NC 27699 161�
11.Borehole.diamet•er. L w/ � . (i) 24b.For Inlectiqu Wells:Co' to D
PYWR,Underground Injection Control(IUC)
• Progrem,1636 MSC,Raleigh,NC 27699=1636
12.Well construction method • IR(�a hi •a • . ,
(ao:auge;mhcy,w61e;duectpurb,ate) '24c.•F r Wafer Supply and Oven_LoP oP Geotbcrmallteturii Wells:Copy to the. . .. • county cnvironmwital3realth department optic county where installed ;
FOR WATER SUPPLY WELLS ONLY
' _ 13a.Yield m 24d.For Water Wells proddcing over 100 000.Gil):COPY to DWit,CCPCUA(P ) � •` Method of test: -' a - . • Permit Proprem,1611 MSC,Raleigh,NG 27699-1611 t+:
1, Al..:_._
136.Disinfection typal 'f ' =
Amount: . . 1 is.
Form'GW 1 Nortb Ccoliva Deparbeent ofEuvirdumeaW Quality-Divided of WaterReaources ---
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