GW1--04310_Well Construction - GW1_20240722

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V�LLL CONSTRUCTION RE. CO _ (GW-11 For Internal Use Only •
1.Well oatracbr-Info tiea;
risk- .. cP tl .?� ��p •
• I v •It WATER ZONIS
WeltCoatraWorNrf. / PROM TO •nssatn�mn
53 �.. . /00 ft-. r.20 rt- .
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NC Well Coatnactor Certification Number •
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13 I^U I l l -�V s 15.OUTER CASINO(Ion ruual card wel6 OR I nTap gable)
FROM TO _ DIAMETER I T> 1 MATIaUL
e�N•m. •
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2.Well Construction Permit N: '��` �O� f • I INNER CAsniO OR.TURING(geothermal defied-bop) .
Lot a!1 apCons r wall cots Permit
PROM TO — .nAurrin •
permits(Lc(AC,C tnaotrss MATsaIAt
County,State, -r+ance...IG) -1-l R. �/L/ Il,' s�,, bL � ^
3.Well Use(check well age): 1 p / — I�7�C s1 I/yt''
R. It. In
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Water Supply Well:
47.SCREEN -
• OAgricullurel •OMraricipaVAtbfjc FROMtc TO ft. 'IMMIXSLOTSIrs IEICICHESJI MATERIAL
OGeothermal(Heating/Cooling Supply) identiel Water Supply(single) — I
❑IndustrieU id
Industrial/Commercial R fa'
ential Water Supply(Idrued) — .
0lmgatiop - lI GRODT
OWdb>100,030GPD FROM To _—� MA MmW1TMfTHOD&AMOUNT
Nos-Water Supply Well: - O ft. 2 _ �
n. NC'0. .
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' OMonitorin •OR ' 1. 11 r >'
• Injection Well: •
erwr«y !t- n. MOY.k 6. lflp LA-r 1
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OAquifirRecharge °GroundwaterRemediation
❑Aquifer Storage and Recovery OSalinily Banria • L.SAND/GRAVELPAh i(:(If applicable) . .
FROM TO
°Aquifer Test OStoemwaterDrainage rt— MATERIAL > rLAC�fSliTMrTSOD
°Experimental Technology ❑Subsidence Control • _ ft. —
• rt,
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OGeolhemia!(Closed Loop) OTra cr '20.DRILLING LOG(aback additional sheets if aaeaaq)
°Geothermal(HeatinglCouling Return) ❑Other(explain under N21 Remarks) FROMTO _DLSCAII!rlQ (sole,halos,saat,o�rape,grails hbe,ere)
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4.Date wel(s)Completed: 7-17.- 2.f Well IDfi • r- •ti.
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5 ell Locating: ^ • rt. ft.. 1;ssP I r-
v' el I . - �— -
• Faer7ityu/Oneer Naase//� /� Foer�ity IDI(if applicable) it rt, Si_)
07 I4 k tRd4, I(� . Al- . 4h P' ..R • it
ft.P •
hysical Address,Address,�y and Zip (! d
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21.REMARKS( info::
County Pascal identification No.(PIN)
5b.Latitude and longitude be degrees/miaates/iecoads or decimal degrees:(if well field,one I.Nlons is.atbCieat)
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/! ..W S�' ` ,� 2z Certification:
G N. 22 ' WcArd &t
6.Is(are)the well(s): �1Permaaeat, or °Temporary 7�G 2 Y
'` //7 9tsoahae we oninctor Dale
7.Is this a repair to as exlstia BY signing this form.I hereby cai that the wd/(s)was(ware)cnwaercredtn accordance with
g well:' ❑Yes or eyNe. /SA ACC'02C:0100 or'IS)I II'CfC 02C.0200 Well COntiruction
if rht,is a repair,fthl out brown well car macron Information explain the,, of the of thq record hag been p►mided no the way oawer. Siassdardg and Mai°COPY
'repot?.ceder Ill remarks ream or on the back of thb form.
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23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the germs You may use the back of this pogo to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Rercariut Box).You may also attach additional pages if necessary.
drilled:
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G d�U - 14.SUBMIT rAL INSTRUCTIONS
9.Total well depth below land surface:For multiple wells list all depthsIIfd�.re,w(example-3®]00,and;W;WOO) (ff) Submit this GW-1 within 30 days of well completion
p per the following:
10.Static water heel below top of`easing: 86 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR
If water level k ohm's casing:arc-+- •, Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 • ),
11.Borehole diameter. /UU« (i/� fin.) 24b.For Ialectlon 11_.. ; Copy to DWR,Underground
Program,1636 MSC.Raleigh,NC 27699-1636 htjectnon Control(IUC)
U.Well construction method: O + e7."r • A 1 r
(t. aria'rotary,cable,direct push eta) 24c.For Water Sy and O u-Loo Geothermal Reran Wein:Copy
• FOR WATER SUPPLY WELLS ONLY: to the
• CO1ntY eays rn onm eprrntment o the crnnoty
)�// 24d.For Wafer Wells Drodnide over 100,000 GPD •
to
13a.Yield(6Pm) , . Method of test: ., j r Ponnit Program,1611 MSC, etgh,NC 27699-1611 :Cop) Dom' vA
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13b.Disinfection type: Amount /0 '✓ • -
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