GW1--02504_Well Construction - GW1_20240422

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' WELL CONSTRUCTION RECO . •
.(GW-1) For Internal Use Only: ' .. . .
1.Well Contractdr•Info tion:
I�wwTERzoN�s i.
Well j
PROM TO DPSCIUPTION
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•35.3 5- .�pO't 4f?.O.ft
f. ft
• NC Well Comutoi CactifieationNtnnur
y , 15.OUTER CASING(for milli-eased wells OR LINER gray Ruble)
Ai+l! t i).�+r IRtOM J TO . DIAMErIR 1HICIQVfSS MA1lRIAL
Company Name. R I R I ��
`n U.INNER CASING OR TUBING(ieathermal dosed-Igoe). 2.Well Construction Permit H: .2-7 l0[ 6. 4 ' • PROM TO DI THIS , MA•�L ' `
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LIrt all applicable well conitniction penile(Le.UIC,Camp,State,Variance,me) -I-1.:.ft• 11.6 ft.... •'iSire Its P•
,.3.Well Use(cheek well use): , '
Water Su ply WeR: 47.SCREEN
O CUltUfal PROM-• TO DIAAffl R SLOT SIZE THICKNESS MATERIAL
•• Agn 'OMtnicipal/Public ft t< - is
OGeothermal(Heating/Cooling Supply) / side:diel Water Supply(single) • .
Olndustrial/Commerciel.• • .OResidential'Water''Supply(s> ,.
Okri he •
1 .GROUT : . .
ga S OWells>100,060GPD ' PROM•.• TO - MA EMPLACRwurrr&IMOD&Amotmr
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Non-Water Supply Well: - _ tt ft e!( 7 y 1?G.[.J�
• OManitonng ORecovery ft ti
Injection Well: 110 • ' • . j�c_und.i;1 -
•• • OAquiferRecharge -OGroundwaterRemediation /
OAquifer Storage and Recovery . OSalhtityBarrier 19.SAiIDIGRAVELPACK(dappl(uble)'
PROM TO . MATERIAL' EMPLtcca:a=moD
°Aquifer Test . , OStomwaterDrainaga R ft
OBxperimental Technology °Subsidence Control !e IL
• OGeothennal(Closed Loop) . '- .OTracer
• '20.DRILLING LOG(attach additional sheeb if neegaaq)
OGeothermal(Heating/Cooling Return) OOlher(explain under#21 Remadcs) PROM 'TO •' DZSCRn'TION(ester,&dam,sw.lt.k true.enh iae,et '
:,4.Date Well(s)Completed:�. '1,21 well ipii
Si.WellLocatsoni , .' '� `
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• FaetlitylOwnerNsme, .". FaciLityBM(if applicable) ' f ft• :APR: G. G'LGC4
_ a2I -SparJ1. - •�i.ph /K� c , • ;'ft . R • .
- ' , '.Physical Address,City, yip ft
(/ IY_s .. • 21.REMARHS/
County Parcel Identification No.(PIN) : .
- 56.Latitude and longitude in degrees/minutea/aeconds or decimal.degrees: ,
• (ifwelll field,one ht/long is sufficient) '
3r 3D N I t I 22.Certification:
,',, . ‘71-_:/..;=,-_? ... ...
6.Is are the wells: C!
( ) O rmanent•,or OTemporary- ��� � Si ;C - Well Contractor Data
- 9ysign'ng ihisfom,Iherebycat°,ibat i/ie trellrrhwar(Seen)coniavetedIn aaordaneewph•.
• 7.Is this a repair to au existing well: Oyes, or. No• 15AIYCAC 02C:0100 or'251 lICAC 02C.0200 Well C9r ispeion Standards and that a copy .
Ifthis h a repair;fill out known well connrucllon Information and e'loin the name of t1 e , o/t is record has been provided(a the well owner• •repair'under121 remark section oron the back of this form. . - ''
• ' 23.Site diagram or additional well details:': • _
S.For Geoprobe/DPT or Cloiea-Loop Geothermal Wells having the semi You may use the back of this page to provido additional well construction info' 'construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells • (add'See 0vet'in Rdaiark Box).You ' '
drilled: ) may plso eBach additional pages if necessary.
�� fJ ,24.SUBMITTAL INSTRUCTIONS ' ' -
9.Total well depth•below land surface:•' ' ' (R) ., 'i
Formulliple wells bat MI depths If different(crimple-3va 200'and 20100' Submit this GW 1 within 30 days of well completion per the followings • •'
' . •- 10.Static water level below.top o1,criaing: • G 0 ft 124a. For All Wells: Original form to Division of Water Resources (DWR),
f water level is above cat/rsg;irre/-+- ✓ •( ) Information Pmeessiog Unit,1617 MSC,Raleigh,NC 27699-1617. •• •
11 Borehole diameter. 1p �d246.For Iniecdon Wells: to D
(in.) CoPy WR,Underground injection Control(IUC)•°,
Program,1636 MSC,Raleigh,NC 27699-1636 '
12.Wdl construction method: %� /� h, •` . S
• ' - ' •• (Le.innn lousy,cable,di ectpusq eta) !, ` '..•• ,f�..- county eav24c.For Water Sappy and Olsen-Loon Geothetuial Return Wells:
uonmaitel heal Copy to the
FOR WATER SUPPLY WELLS ONLY:! •
health deparhnent of the county where installed ,
Li
�/ n 24d.For Water.Wells produdtif over 100 000 GPD:Copy to DWR,'CCPCUA••
13a.Yield(gpm) `T Method of test: ( Permit Pmguim,1611 MSC,Raleigh;NC27699-1611 . •• ill ��! �f- • , ti
136.Disiefe•ction�type: iil Amount: /O — .
•Foif(3W 1 . ,, -.