GW1--01975_Well Construction - GW1_20240401

•
CONSTRUCTION RECO ,(GW-1) For Internal Use •..
1.Well Contra ormation: a Only: --
• le.WAT$RZONES . t -
WellCoetracterN 666��/// • . PROM TO DPSCRn7ION -
5.ti7 /� Asa ft• 32o ft • 11, • . -- • ' "....•
`NC Well Contrictor cartiHcdion Number - . ft : ' -
15.OUTER CASING(for multi-cased welt)OR LINER(if ap liable)
1 ' DIAMEriiR THICIWZSS MATiRIA1,
Company {t I • •, ,ft I ' •- .L• m• I r ,. • -
•2.Well Construction Permit'll: I Q' 1 • 1/✓ 16.INNER CASING OR TUBING(E.eotb'erms1 doled-loop) :-'• .-• •
PROM TO DIAMETER TEIC6TIPS9 " MATERIAL_List al applicable wdl eoi enue Pon psalm 0.e.UIC,Cannot Stale,Variance ein) ft 416.r 7 ,4 .
3.Well Use(check well lie): �'
• Water Supply Well: . • 47.SCREEN L
DAgriculttual. OManiC➢paUPubliC PROM TO DIAMI ER 6 :SLOTSIZE THICm�IESS MATERIAL -
ft
OGeothennal(Heating/Cooling Supply) , residential Water Supply(single) m 1
. m . in 1
.Olndustral/Commerciel OResidential'Water Supply(� 1g,cRoor � y •
' � OLrigatio( ,. - OWclls>100,000 GPD ' PROM. TO. M - n►>PLncauNrMcraoD&AMOUNT
' Non-Water Supply Well: ': fE
d 7- -I •-/V 2ci �'. /VI * ./
. OMooitoring-- - -- Reaovnry'" - s 1 - . - _.
Injection Well: • • R 1
DAquiferRecharge . ' ' - -OGround ... ft ft
water ltemtxliation
• LLL-
OAquifer Storage and Recovery OSelinity Barrier• 19.SAND/GRAVEL PACK Of applicable) , • , ,D •
PROM TO MATERIAL •- IMPLACPMENrMETHOD DAquiferTest. ' - OStormwaterDreinage . ' ft
•
_• DExperunentel Technology / 0.Subsidenca Control ' '. ft ItDGeolhemial(Closed Loop) / 'OTracer . • '20.DRILLING LOG(attach additional sheets if neeesssry) -
'
DGeothermal(Heating/CoolinggRetun) . OOther(explainunder#21Remarks) IRtOitf TO L. .' - • DESCRIP'rrON(alsr,hsrineai,saa/rsektips grab' ota)
4 Date Weil(s)Completed:'-3 i -LI, ID# • ft ss,
-Well
Sn-WellLocatieu:. 1 ;;-,
Facility/ Name/ _) T FacIlityy11Dit(if applicable) -ft ft ..
5-ll i•t K ctAin b or) 1•►-a�1.1- k y 7(1. .. - •-ft*
ft 1 .E';• �"^ .5
Phj'aial Addles,,City,and Zip' - ' ' 1 l . � ,•^ �, i •, ,.
Li...* 21•REh1ARKSl r�F'N .z3 •I
County, . - a Pi rs1Identi6aticulio.(PIN) i t �Ut 7
56.Latitude and longitude in degreed!dnutts/seeonds or decimal degrees:
L`,-
(ifwell field,one latflong is auffciei) • w • • '" -[, .. • - 3.�/KAf
•
i.
6,Is(are)the well(s): rmanent Or:'OTemporary'• Z ii siiiwhue' Cal ed•Well Contractor
1 ? .. Data'
- Byrlgnl gth4jom,'Ihereby'cerrfythatthawei/(rf war(were)consvnictedIiaccordaneewih
7.Is-this a.repair to an existing Well: OYea or o• •• 154 NCfC 02C:0100 or'73,Y NC.4C 02C.0200 Well Cvnelencilon Standards and Ma a copy , .
.If this Ira repair,fill Cal blown well eonrlruc0on Inforinatton_ oin the naiwe of the ofthis record has been provided to dna Fell awns..''
repair under ill rema'b section or on the backofthlrfotm • ' \ '
• : , . • . ''• 23 Site diagram or additional well details
8.For Geoprobc/DPT or Qosed-Loop Geotheroial Wells having the same I •• You may use the back Of this page,to provide additional well construction info construction,only l OW-1 is neerleiLs,ledicato TOTAL NUMBER of wells ' ' (add!See Over'imRlmerlcb Box):Youxmay also attach additional pages ifnccessary
24.SUDleffI TAL INSTRU IONS '
'- ". 9.Total well depth below land surface • -3 2-6. -• . • • I _
••Frmulnpleliell,rlletel/de hr di (example- .., . SubraltthisOW-iwithin30.daysofweellcompletionper�thefollowing:' '
pr If fjersnl amar k-3Va 200'and i(�100�
10.Static water level below top of ciwiu - •24a.:For All Wells: Original`form to Division of Water Resources WR, "Ifwatel level le above eadn&;use"+i ' '(ft) Information Piocessing Unit,1617 MSC!Raleigh,NC 27699-1617 )
11 Borehole diameter ' (� b (�,) ; 24b.For Inlectton Wells:Copy fa DWR,Underground lnjection•Control C
Program,163G MSC,Raleigh,NC 27¢9.9-1636 7 )
1Rofzi,1_ 1It4
• 12 Welk construction method � 'Y(ae auger missy cable,direct push,ate). • 24c.,For.Water Suppl and Open-Loop Geotiaer salhetuia wells:Copy to the '
county environmentol health department of the county where i stalled
:. FOR WATER SUPPLY WELLS ONLY . '
y • >r
,. . 24d.For Water.Wells proddcini ova r.100.000.GPD Copy to DWR,CCPCUA
13a.Yield(gpm)' I 0 '. 'Method of lest; C - • , Permit Program,1611 MSC,Raleigh,NC 27�99-1611
13b.Disinfection type: ' '�` Amount: d GN t'
Form OW 1 •r. - .. ' .
NadiCamJmaDsimaotofEivied�eatalQuaiity-DivisionofWaterRe o _ _t lYCOa 1� n_a_..