GW1--04311_Well Construction - GW1_20240722

•
WELL CONSTRUCTION RECO (GW-1) For Internal Use Oiily_
1.Well Contractor-Information:
•
LI.WATER ZONES
Well Contractor Name FROM TO DISCRIFTTON
• 3 5 3 .3 l vvtc' � ft •
rt. ? Ii.
NC Well Contactor Certification Number •
15.OUTER CASING(kr multi-rased wells)OR LINER(If ap Stable)
J i.-' '�-1•,�lr I
s FROM To
ft. fj DIAMETER 7ffiCKNLSS q MATERIAL
ManComp.ny qs. . 11
16.INNER CASING OIi.TUBING(Geothermal dosed-I.op)
2.Well Construction Permit#: 6--4/tir-) -Lit---k__- • FROM TO DIAMETER Tmann=ss MATERIAL
List all applicable well construction permits(t e.VIC County,State,Variance,etc) 1-I n• op n• s j7/1ji Ia. Th1-e r L
3.Well Use(check well use): n n• is Ki
W t Supply Well: j7.SCREEN
cultural FROM TO DIAMETER SLOT SIZEI 7ffiCKNESSI MAIIRIAL
LLLAgri .❑Mtnicipal/Public • ft. - ft. in,
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) .
ft R Id'
❑Industrial/Commercial ❑Residential Water Supply(shared) •
•
la.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO -MATERIAL EMFIACTMINT METHOD&AMOUNT
Non-Water Supply Well: • 0 R' Z3 ' Alegi' AA ,x-,a
• ❑Monitoring ❑Recovery• ft- is
Injection Well: POY1B".t • p f�l..1 •. (
❑A uiferft. ft.
19q Recharge ❑GroundwaterRemediation
❑Aquifer Storage and Recovery ❑Salinity Barrier . SAND/GItFROM TO L PACK( pplinAbLle) •
tMiIACEMENT bfETROD
❑Aquifer Test ❑Stormwater Drainage ' - ft R
•
❑Experimental Technology ❑Subsidence Control ft. ft..
•
• ❑Geothermal(Closed Loop) OTracer '20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTIQN(rater,hardens,seWreck toe,nabs size,etc)
8 ft It
4.Date Well(s)Completed: 7-1 -21 Well ID# • ft 'ft. •ft. it `
5a.Well Location:
Oh l Iv o oa • ft ft J
• Facility/Owner Name Facility 1D 1(if applicable) ft ft r
I- 21- 2<phhr- AVl} , Parr, - c�.1I1�- ft. tip
1�rJ
PhysicalAddress,City,and �yt�- R ft. ,
osigi
S l t r Se j '1 11.REMARifS(• _
County Parcel Identification No.(PIN) • •+ r",
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell Sold,one lat/long u sufficient)
3 / r )4 ' II N e 22.Ccrtifi a6on: � � ,
(� �Sb ' S3 ' ZI • w , v
6.Is(are)the well(s): Permanent• or OTemporary t �� l
�`�/// / 0 Srgoahue of C - ei iVell Cophactor Date
igning this
7.Is this a repair to an existing well: ❑Yes or, No 1S •
A C 02C�:oioo orISANC,4C 02C.0200by certft,that the (Well Construction Sindards d�Ce that a copy If this it a repair,fill out brown well c»rurr uction Information explain the nature of the 44liii record has been provided to the well owner.
'repair under Ill remark,section or on the back of this foie.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 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 Rdriarks Box).You may also attach additional pages if necessa y.
drilled:
C 24.SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: -.J 6 's
For multiple wells list all depths fdyferent(example-3®200'and 2@00') (ft') Submit this GW-1 within 30 days of well completion
y p per the following:
b!
10.Static water level below top of casing: C Q (n) 24a. For All Wells: Orij1inal form to Division of Water Resources •
If water lose!Is above carinF:Ise'+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 ' �WR)�
11.Borehole diameter. •in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
12.Welt construction method: 'a + 3-r-1 . Program,1636 MSC,Raleigh,NC 27699-1636
(Le.auger.rotary,cable,died r -
push,etc.) 24c.For Water Sa 1 and Opea-Loop Geotheral Return Wells:Copy to the
cors�ty eavaonmen Eh department o the iocounty ere costal!
• FOR WATER SUPPLY WELLS ONLY:
24d. ohm Water Wells radicle;over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) I+ Method of test A; r • Nand Program,1 L 1 MS Raleigh,NC 27699-1611
i%
13b.Disinfection type:._ 7U Amours tY r.-✓ .
F��ITV 1