GW1--04203_Well Construction - GW1_20240717

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WE!.T,CONS'I1(UCTION RECO .(GW-11 For Internal Use Only .
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1.Well Cos cto erns sL : ��..
• - •14.WATER ZONES
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• Well Caoa.aorMan PROM TO rrrsaranon
3 5. ..5. _/vo f o
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R IL
NC Well Codndar Codification Number
15.OUTER CASING(fur mdtl-used was OR LINER(if op Stable)5ry 'h e_v s FROM TO IL DIAMETER TRICKNE33 MATERIAL _
R. DIAMETERlet
Cesmp..ry Name
jj �( ) I EI ER CA OR TUBING(cattier-End d.fd-leap)
w FROM TO .DIAMETER' MATERIAL
2.Well Construction Permit 0: U
Llrt all applicable well constructton panda e.WC Carwy,Srue,Vwianca,.lc) _i..1 R X,.j It ry Y 76( la f/
1 1 C.‘, l'L
3.Well Use(cheek well use): R. It I.. •
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Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT Br= T
K?eLSJ MATERIAL
❑Agnculturnl taticipal/Public R ft. Is.
❑Geothermal(Heating/Cooling Supply) identid Water Supply(single) . ft. R — ha..
❑lnduatrial/Commerciel Residential'Water Supply(shared) la.GROUT •
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❑lrrigetioRr ❑WdIS>160,000 GPO FROM TO — a[A , >�1A M�oD&AMDUM
Non-Noe O 2 ? Z" r e-tA.-'t1' �L4I ')(r�,i
❑Monitoring ❑R �O Y} Lan d �� ,
Injection Well: •
ecovety R It p .e
R It
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0 Aquifer Recharge ❑Groundwater Remediation
uifa S U.SAND/GRAVEL?LCIC(If applicable)
OA q Storage and Recovery ❑Sal nity Barrier - FROM TO MATERIAL El aIACEMINr METHOD
❑Aquifer Test ❑StonnweterDrainage . it. R
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❑Experimental Technology ❑Subsidence Control ft. fit
• ❑Goothennal(Closed Loop) ❑Tracer •20.DRILLING LOG(e teat additlonal sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 021 Remarks) FROM
TO DESCnarlgN(eater,lariats,s.a4.ek erp�,gran axe,nee)
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4.Date Well(s)Completed: 7 4 -l Well IDff rt. IL J
ea}'-c•
Location: rt. rt.5a. ell L 5' Y
0 (o(61 i to i•3-e- R R
L G
• Faoiiity/OwnerName Fatally ID/(if applicable) ft. ft. '
+zt -- 3rkA`il 1 ),A\ Rd - ---.-ft. . ft. . . __ _
Physical Addraw.City,and Zip ft. ft. `'
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l V' I • 11.RZMARif9/
sty Parcel ldeatifreat on Ho.(PIN) • 1 f 2074 •
fib.Latitude and longitude hi degrees/minutes/seconds or decimal degrees: y ._,g !Jt_k
(if well field,nee Talton`ii sufficient)
to'
v 22 Ccrt(I tine: eio t ti ![
6.Is(are)the well(s):yPermeneut or ❑Temporar•y Sioe.tnee of CatiSed•Well,Contractar Date
7.I,this a repair to an existingwell: ❑Xa or By signing this form.I hereby ceri 5,that(ha well(,)wu,(were)constructed In accordance wit/
No ISA NC.IC 02C:o1 c/0 orIll NCAC 02C.0200 Well Construction Standard,and that a cop)
If this Is a repair,fill or known well comp ratan h forrrrtion explain the natant tithe ojthp"cord Ira best
repair order Ill remarks section or on the bock of this form. P�yded it,the well owner
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the mane You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed Indicate TOTAL NUMBER of wells (add'3ex Ova in Ricaris Box).You may also attach additional pages ifnecessary
drilled:
• Z D 24.SUBMITTAL INSTRUCTIONS '
9.Told well depth below land surface: (R)
For multiple wells list all depths fdylerent(example_3@200'and:WOO') Submit this GW-1'wtthle 30 days of well completion
p per the following:
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10.Static water level below top of casing: 69 d rt 24a. For MI Wells: Original form to Division of Water Resources (DWR),
If water level is above oar ,1;r,e- w �V ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: • /v on,) 24h.For Injection Wells:Copy to DWR,Un
derground Injection Control(RTC)
12.Well construction method: a ±a..rt 1 ._ A f i, Program,1636 MSC,Raleigh,NC 27699 1636
Cep• .rotary,cable,direct pesi4 eta) 24c.For Water Suppl�y.and Opeu-Loop Geotberioal Return Wells:Copy to the
weer
coucty environmental health department of the cotaty where installed
• FOR WATER SUPPLY WELLS ONLY: .
�] 24d.For Water Wells preclude;over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) ( Method of test •-A; r °n P0t(Program,1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: Amouut: 6 A-- -
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