GW1--01976_Well Construction - GW1_20240401

'WELL CONSTRUCTION RECO .~ (GW-1)• For Internal Use Only •
• 1.Well con eronlnfo" lion: �! • _
wwTZRzoxes . y
Well Cos orName' .PROM •TO DESCRIPTION .. .
NC Well Contractor Certification Number' n• R•
,-y 15.OUTER CASING(for multi-caned wells OR (trap ticable) .
: ! ' 0 _vi � , . FROM•: TO . DLlMmst ft.
I � MATERUtI,
2.WellConstrnctionPermif#: I / t 1' • DIAMETER
-• • • • '
FROM TO �/ THICKNESS MATERIAL
Lki all opplleable vrcII ConitnrcHon permlla(I.e.COC,Count,State,Variance,Oa) ! R G3 . R C%t/ ln'
"f f v Thir/l' a 3..Well Use(cheek well nee): R R p
water Supply well: ,
47.SCREEN
OAgricultural.' OMtcuciprllllPttblic PROM • TO DIAMEMIR ' SLOT SIZE •THICKNESS
ft. f6 in. MATERIAL'. -
CGeothermal(Heating/Cooling Supply) identia 1 Water Supply(single) . _
OlndustriaUCommeroial ��• R R
OResidential'Water Supply s' i
PPY(ha� 11+.GROUT �. • ;,
Okrigatio(t •" ': . . . • , OWellsi 100,000 GPD • FROM . . TO - ! +
Non-Water Supply Well: D a
MATERIAL •EMPLACEMENT AMOUNT
Injection Well: DRecoveryr . < R R ' a'r .
i�r1/o h '
' OAquiferTesf , ." ` OStormwa'terDra(nege � R
R P u ,.,-.1IIt.OAquiferRecharge. • •. .. OGroundwaecRemediation ,
, 19.SA1ID/GRAVEL PACB(If applicable) • . - .OAquifer Storage and Recovery .- " OSelit4 Barrier. PROM TO MATTmrAx E�wcnrcNlMs rsoD
.,. ..
•
•• ' OExperimental Technology . / OSubsidemce Control • • R R. ' f
_ -
pGeolherrrtal(Closed LOOP) ` -.if.
' •OTracer I. . • • , .
'20.DRILUNG LOG(attach additional'sheets if necessary)OGeothermal(Heeting/Cooling Return) '' OOther(explain under#21 Remerics EOM TO .. DZ CRIPflO (ul.r,b,e d.m,walnek
i ) bye,vain she,ore.). ,
4 Date Wel(s)Completed: 3 46 24 Well
5a.well Location a ID# I+ .. . .
'' ? a�^+
•
` .pFacl ity/Ownd erN.+:emite F.acili ty ID il(d appbnbl e) !" •
Rf R b'''. t;.e & r.'@I a ..Pi Ad. ,*'11; .. I U 1I1:t'ds„.^ , L .i ► ' •;•R t! . . ."aFR- ) 1,•/ri74 County l.rr
.•, Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds"or decimal degrees:
(ifwell field,one lst/long is sufpcient) - .
3 15 22.Ce Hon: f t
�i: N � �rZi , w • rttl'tca ,
/Lot.. ,40,;.e1- - '"
6. r Is ae the wells:Aeor',( )
O 1 manent-- OTemporary —„ 5ign1bu6 o arti5 •Well Contiaetor
•
7.is this a repair to an existing well: OYea• or o. _ • LIAByti8olesthis fon,Ihereby'eat�that the well(a4 war(weir)eonrfnrded in accordancew ith.,."this tsa repair,fill to an well conflucNon/(Tires
. n aril espial ` oft NC,IC 02C:0100 oi•ovii NC IC 02C.0200 Well CO:intake Standards and that a copy:
'repair underP2.1 remarki section`orair the boekof is form. n this naturr of -•.of.th►i reeotdhar Ueenprw/ded to therrrUminer. . . '
' • ' • • - - - 23.Site diagram or additional well details:
8 For Geoprobe/DPT or Closes-Loop Geothermal Wells having the same . You may_rue the back of this page to'provide additional Well construction info
,, construction,only 1 GW-1 is neede4Indicate TOTAL NUMBER of wells (add'See,Over'in R1nierki Box).You may also attach additional pages ifnecessary.'_, ' '
dulled:
9.Total well depth below land surface. ' 7e if? 24.SUBhI1TTAL INSTRU1�.lIONS f •�' '
• Fin-multiple w l&hit at depths If different(example-3@200'and 28100) • ( ). Submit this OW-1 within 30 days of well completion per the followin •
10 Static water level below fop of casing:'' �O, • i g�
�• {It)., 24i.•For All wells: Original form to Division of Wale':Reso
Ifxaterlevell,abovecaNn&vse"t' IOfcrmetidaprooeasju Una urces "(DWR).: -
• / /J g t;1617 MSC,Raleigh,NC 27699-1617 '
11 Borehole diameter 6 O 24b.For Ina iL.wells:Copy'fo D
NW-1 Unc(erground Injection Control(1UC
Program,1636 irlSCy Raleigh,NC 27699=1636 )
IZ Welteoustruetlogmethod �j
. (i.e.auger,entire cable deed pushy etc. t^
4e.,ForWaferSu' l andO en- o Geot crinal3letuiiiVellsc•Copytothe
courtly cnvuonmental tit department of rho cotmty where eel •,
FOR WATER SUPPLY wEI Y S ONEY:
• pc�For ater Welk roddcin over`100 000.GPD:Copy to
13e:Yield(Rpm) i Method of least: Program. 11 MSC,Raleigh,NC 27699-161 I Dom'CGPCUA
•
136.Disinfectiontype: Ainomt
I•
. A....-•'
Foam GW-I ,North Carolina D .. ''
' �+mtrnentofErv6omneaW Quality-Division of WaterResourcw .