GW1--03650_Well Construction - GW1_20240618

WELT,CONSTRUCTION RECO (GW-1) For Internal Use Only:
1.Well Ceetractor.Tef motion:
14.WATER ZONES
WellCastile .
FROM TO DESCRIPTION
176 ft.' j14 ft.
ft. R
NC Well Contractor Certification Number
15.OUTER CASING(for mold-cared wells OR LINER Of ap Humble)
GvnJ 13 r0 -e_v s PROM ft TO I DIAI1tEiER Iffit]QIISS MATERIAL
Company Name
16.INNER CASING OR TUBING(geothermal dosed-Imp)
2.Well Construction Permit rY: FROM TO DIAMETER TRICIQ.T35 MATERIAL
List all applicable well construction permits(t.e.UIC,Cown'y,State, Variance,etc.) -i-I ft /30 ' eC 'Y In. /Luc r. ai-�'
3.Well Use(cheek well use): ft. ft. /
Water Sapply Well: j7.SCREEN
❑Agricultural ❑Municipal/Public FROM ft. TO ft DIAMETER =l�r:o(= MATERIAL
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) , -
ft ft fa.
❑Industritd/Coromerciel ❑Residential Water Supply(shared) -
1g.GROUT
❑Irrigatio(t ❑Wells>100,000 GPD FROM To F
EMPLACiatswr METHOD&AMOUNT
Non-Water Supply Well: o ft. Pt
` M r X.1.ii
.Monitoring ❑Recovery ft.
Injection Well: / 1 CA"`1
•
0 Aquifer Recharge ❑GroemdwaterRemediation ft ft.
1
❑Aquifer Storage end Recovery ❑Salinity Berrien 19.SAND/GRAVEL/ACK Of applies We) .
FROM TO MATERIAL EMifACEMLNTMEfHOD
❑Aquifer Test ❑Stormwater Drainage ft R
❑Bxperimental Technology ❑Subsidence Control ft. ft.
•
•
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attack additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 1/21 Remarks) FROM nEscxx>pTIQn(velar,harden',',Wreck t �, etc.)-
C ft. at
Date Well(s)Completed:)23^Aq Well IDi1 R .n,
•
5a.,Well Location: R ft 'S r
All f la n ) L G, 1-�o t ft. •rl.,
Facdity/Owner Name Facility Oil(if applicable) • ft ft r 8
77-eM - S/ 10 - Ali t I1 . 0 . . ink,:.,.. -- :,..unit Physical Address,City,and Zip
rt. ft.
Sl,( r h-) 21.REMARKS/ -
County Parcel Identification No.(PIN)
56.Latitude and longitude hi degrees/minutes/seconds or decimal degrees:
(if well field one let/loag is sufficient)
3 t 321 /Z Ye r 1-6• 22.Certification:
\' N / V �• �V /'l�I�
6.Is(are)the well(s): {BPermanent or ❑Tom Ora1 �3 2
///111 P ry / v ! Signature bhrtiV-
Yell Contractor Date
7.Is this a repair to an existing well: ❑Yes or Ni, By signing this form,l hereby cehlf�'tlW the well(s)war(were)constructed in accordance with
Ifthis Is a re ISA NCAC 01C.0100 or'73.d1 NCAC 01C.0100 Well Constn,ction Standards and that a copy
e pair,fall out brown well construction information explain the nature of the °/This record has been provided to the well owner.
repair under till remarks section or on the back of olds form.
23.Site diagram or addiitional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
(add'See Over'in Rtrrarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: a Q
For multiple wells list all depths iifd different(example-3(t�.700'and 1©100') (ft,) Submit Ibis GW-1 within 30 days of well completion P per the following:
10.Static water level below top of easing: 6 0 24a. For All Wells: Original form to Division of Water Resources (DWR
If water level is above oaring.ese"4" (ft') Information Yroeessing Unit,1617 MSC,Ralei )
8 gh,NC 27699-1617
11.Borehole diameter: 8 (in,) 24b.For Ieiectioe Well,.:
Copy to DWR,Underground Injection Control(NC)
12.Weld construction method: �C. a YC j l r PfogfEm.1636 MSC,Raleigh,NC 27699-1636
(i.e.wger,rotary,abk,dieet pusi4 ere.) 24c.For Water Su I and 0 en-L sop Geothermal Return Wells:
County envtrommenta th department o the county a
FOR WATER SUPPLY WELLS ONLY: Copy to the
13a.Yield(gpm) (� 24d.For Water Wells rodocine over 100,000 GPI•C
Method of test: j ►' Permit Program,1611 M Cam,Raletgh,NC 27G9`g_161 °�to Dom'C��A
it
13b.Disinfection type: Amount: ht,-