GW1--01982_Well Construction - GW1_20240401

WELL CONSTRUCTION RECO (GW-1) '
For Internal Use Only
os
1.well Co ctor. nfo, o� 4:'• _
1 i
Well Conaactorxame '14 WATER ZONES . I• I
FROM TO DISCIUPTION
`353'5 , cod fL. 412Pft. I I _
' NC Well Contactor CartiSoedoiiNu�b� ; • rt
• n' )/3 15.OUTER CASING(for multi-eaaed'wells OR LINER(if op lieeble)
/[/U j`� j •PROM ; TO . : DIAMETER 4 -
Company Name !t I tti I THICKNESS 1 MATERIAL
/A) I
2.Well ConstructionPermif#: l V" L AO 7 d f) 'Ai-. ]6.INNER CASING ORIIIBING(Reotltermd doled-loon)
- List all appbcabk well conrauctlon PROM TO DIAMtrER TSICIWtS9 ••' MATERIAL
penults(l s• UJ( County,State,Variance,eta) ft ft
, " 3.Well Use(check well use). • -•. ''.-1-I' G s�" !Ch- l'Vv
Water Supply Well • 17.SCREEN
OAgriculhual. OMimiclpz3UPiiblic • FROM TO ' DIAMETER SLOT SIZE •THICiWess MATERIAL
DGeothermel(Heating,/Cooling SuPPlY) tdential Water S n a ft !e i i
OTndushrial/Commerciel el uPP 1 Y(siBI) fl: ft. hi„! '.
�Residenti 'Water SuPPlY(shared) r' _
Ohrigatic><t' .. , • • 11f.GRODT -
OWclls>100,000 GPD ° . .FROM TO MA EMPLACEMENTME IOD'&AMOUNr
Non;Water Supply Well. • ,.` ft. r
OMoaitoring -`DReaovery .. t/ - J I . t •+r,'
Injection Well: • to •�p/�� p OAquiferRecharge •OGroundwaterRemediation ' - !t
OAgwferStorageandRecoV�y'ti DSelinilyBarrier 19.SAND/GRAVEL PACK Of applicable) • • '. "' . �. , '
PROM To • MATERIAL - sn�LAcia►rnvl METsoD
OAqutferTesE • OStomtwaterDrainage {. , n m
DExperuaental Technology :OSubsidence Control • -
pGeothermal(Closed Loop) d 1 . OTlacer
':` `20.DIULLING LOG(attach additional sheets if neces dry)
0 Geothermal(lieating/Cooling Return) ' OOther(explain under#21 Remazks) FROM• - TO - • DISCIUPTIUN(solar,hardness.ssWncic tree,cram."ate.)
4.Date Well(s)Completed' 3 3 -z`-� I L
Well ID# rc ff
Sa WallLoeatian ft" it
Fertility/OwnerNamd 'FaclityID (ifapplicablo) !t !(, • •
Gin-,I ros 2�P S-I-0 s• 122 rh, .ri�' iv,',..:
:
Physical Addreis,City,and Zip . ' ' '�{`
-5u k r -1 ' . • • , ' , `.. 21.11E14IARES/ APR e, eilZa
County 1, '' ;a Parcel Identification No.
trn'a,i,p ,i f ,:5, it 4.UF�A
It Sb.Latitude a•nd longitude in degreea/minutes/seconds or decimal degrees: -. i i r•i•ti s0.�r•lc,• -
(ifwe/U field,one Iat/loag u sufficient).
1p ! ' a v ..?j Gi t /S 1 t 22.Cerfifiea6on:• -N � - I.
6.is(are)the well(s)i armament or l7Temporary SiOoatrre bf ed ell Contractor. . ' Date
hat
7.Is this a repair rain existing well: OYes or No• -.. Y NCAC 02C.0100 or]ANC lCt 02C.020 rWel Cwasan r ctlon constructed
dard,and that a copy
IfthleIrarepair,fill oat;mom well constracuon Informed° n the nature of the ; ofthis record has beenprovlded to the well oemer. ,repair under#21 remarkr section or on the back of shisjonu '
' • ` -,. • 23.Site diagram or additional well details . '
8 For Geoprobe/DPT or Closed Loop Geothermal Weds having the same You may use the back of this pago,to provide'additional well construction info.
constructor,'only 1 GW I is necde Indicato TOTAL NUMBER of wells • (add'Se c Over'in Rr marls BOX)You may also ath+cb addiGooal pages ifnecessary
drilledi
, " • .24.SIIB&ITI'TAL INSTRUIONS
9 Total well depth below land surface r
' T 2O , ' (ft.). "• ' '' ••• '
ormultrple wells list all depths ttid�irent(example_3@loo and 2®l00' Submit this OW-1 within 30 days of Well completion per the following:
•
•
,
F
10.,Statrc water level below top of casmg:� • 24i?For AU Wells: Original ford to Division'of Water Resources (DWR)
re
i ft
If wafer level Is above earls$;ure"//+• (/ .Information Processing Unit.1617 MSC Raleigh,NC 27699 1617
11 Borehole diameter •l9 IO . :'•(m,), 246.For In1ecHgn Wells:Co to D
• 163E MSC, py Underground Injection Control(IUC)
12.Well coustrueHon method: • ��+a 1�,� Pro Rale��,NC 27499=163ti
(i°•auger rotary able direptpusb,etc) • 24c.,For Water Supply and Open-Loop Geothermal Return Wells Copy to the
county environmental health departurentiof the county where installed
FOR WATER SUPPLY WELLS ONLY:'
24d.For Water W• ells p• roddclni over 100,000.GPD Copy to DWR.CCPCUA 13a Yield m a_...„,_ Permit Program,1611•MSC,Raleigh,N•C 27699-16i 1
(EP ) ,� - Method of test
13b Disinfection type - I / -•Amount V. e'lJ
,.F°,mow 1 � •
is
• Noithr. '
Iiaa D:partment ofErvudmaeatal Quality-Division o •fWaterReaonrcos is .._:_