GW1--02913_Well Construction - GW1_20240510

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WELL CONSTRUCTION RECO (GW-1) For internal Use Only: i
1.Well C trectrianf *Bo I
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14.WATER ZONES i .t r •
Well CantndorNamo FROM " TO I DESCRIPTION
3S.3 5 lov ' Sao n i '. '
• ' NC Well Contractor Certi6cationNumber •
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J y�� 15.OUTER CASING(for multi-caned wept OR LINER((ap liable).s;•-
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`I�/vimiA i r G[A' /. ,�J1 FROM • DTAMTraR . i Tffl ViSS MATTaUAL
Company Name IT0
fk J
in `
i ,- • / 16.INNER CASING OR'TUHING(Re thermal doled loan) Vt"
2.Well Construction Permit#: • —1-1) Y • PROM TO DTAMTPTR IIUCICN SS. MA• yy
l41 all applicable Nell eo►nructlen permit:(r a UIC.Ca my,Sate.Var/miey de.) '/$ fr:, S7 tat,
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• 3.Well Use(check well use): R, Mir /
Water Supply Well: ,• ,17.SCREEN .
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• °Agricultural °Mtmicipel/1'ubhc FROM • Toft. D1AMLTRR SLOTSIZ! Tin ac ss MATLRLVL• •
°Geothermal(Heating/Cooling Supply) esidential Water Supply(single) . , ft. i to;
°lndustrial/Commercial identiol'Water'Supply(shared) - ,
• °hri ho ]a.GROUT ,
ga• n °Wells>100,000 GPD -• . FROM'• TO !MA • EMi+MA OD&AMOUNT Non-Water Supply Well: � � �//�uT�s
°Monitoring • °Recovery '�.� r�La '' / C�,/vl : .�f.'•
- Injection Well: ' n" .f�Y d AP'-'r4
OAquiferRcharge - °GroundwaterReme •
dion O/ /�
°Aquifer5torage'aridRecovery °SaluiityBerrier •
19. D/GRAVELPACKinappliable) - .
PROM. TO . -MATZRIAL ximiu mENTMTIHOD
°Aquifer Test DStomiwaterDrainage
°Experimental Technology °Subsidence Control ' • (t, n• '"'
• ' °Geothermal(Closed Loop) , • OTracer '20.DRILLING LOG(attach additional sheets if necemarr)
4OGeothemtel(tieating/Cooling Return) °Other(explain under{l21 Remarks) PROM • TO- • DESCRIPTION(Wee,kardIan,nlFnek tree,grate she.eta) , •
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, ft. ft.
.Date Wall(s)Cohrp"leted: '•••(1-43 Z'f Well ID# m tt
'5a.Well Location C •
• vGl n 601 ft.
e•I I t . •-. • ft. f •_ [ .. ,,.
• Factii /Owne:Tame ..�1- CI- Fictlity16(if appliable) ft. R
14w11 .er`� L , ', rjtsh C 1'�2e�- _.f` "MAY' �" vuZO[
Phy�sicall ddtess,City,and A) ,' •
V l/l�L�l 1 k a-., • 21.REfl1A1tI{5 i la,`V i'Y z c4r Cl ;a f� v.?'- ,
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County Parcel Identification No.(PIN) ,
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56.Latitude and longitude in degrees/miuutes/aeconds or decimal degrees:
• (if well Raid,one let/long is aaffieient)
3�, a1 r 5Z N YD l" 5 5�' 22.Certification: �L
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' 6.Is(are)the well(s). ermanent or OTemporary• Shanahan ofit,f ti6 .
- - - - �..- - - . -. --� ... _ - Nell Contractor Date /-_ <
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�' gyNgn lag rh Maim.lherebyeerr/fyrhais/umll(r)war(ware)eonetruetedInaeeordaneewIds
•7.Is this a repair to an existing well: oyes •or/�No•• as t AVAC 02C:ONCO or'ISJANCAC OIC.0200 Well Construction Staaadaid,and that a-eopy ..
' !Oils 1sa repair,fill out lawn well eonravctlon iryfornailo,mat erpla/n the nature ofthe of this'record has beenprovlded to the well owner
:repair'wder f121 remark sullen or on the back ofthlsfonn.
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23.Situ diagram or additional well details: '8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Youo may use the back of this page'to provide additional well construction info •
Construction,only 1 GW-1 1 is needed Indicate TOTAL NUMBER ofwells • ( See Oven inReaiarka Box).Youmay also•attach additionafpages ifaecessary,
drilled: -
• • ' 24."SUBMITTAL INSTRUCTIONS" f . .
9.Total well depth below land surface. D �.
For multiple wells list all depths jdlfjeient(ewmple-3g200'and 2@10�. • . (�) Submit'this GW-1 within 30 days of Well completion per the following: -
10.Static water lapel below fop o casm; /1-0 (IL) 24a. For All Wells: Orig`al Ifmun to Division of,Water Resou�,y (DWR),7
Ifwaferlevellsabovecasing care-+g )' 7nformationProc•
essingUttit,1G17MSC Raleigh,NC27699-1617
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11.Borehole diameter. (� 1 r ;
°" cm) • 24b.For Inlection Wells:Copy to DWR,Underground Injection"Control
• - . ', \ O l� /+ Progetn,1636 MSC,Raleigh,'NC 27699-1636 �C)''12.Wait construction method \ 7 !�(,�`. l
(La nigc;rotary.able,directpusl>,etc•) ,. county For Water Snap'',and Open-Loop Geothermal Return Wells:Copy to the '
environmental health department of the county where installed •i -
G 24d.For Water Wells prodddli•over 100,000 GPD:Copy
to DWR,
13a.Yield(gpm) -• 1 5 '.,' Method of feet: • Permit t;�,1611 MSC,Raleigh;NC 27699-1611 'CCPCUA
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13b.Disinfection type: 1 t / [4 Aniounk �'�• �'
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• 'Fenn riw 1 - /r 1 •-