GW1--05002_Well Construction - GW1_20240828

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WELL CONSTRUCTION RECO (GW-11 For Internal Use Only:
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1.Well C ctor.I■ atlo
:4 .
•14.WATER LONIS
WeD oc ass FROM3.1-7"-- ' .
rt' TO�ft.
.4511A ft. ft.n
NC Well Contractor Certification Number
U ]S.ROUTER CASINO(for m DIAMETER
I. ORT UWER(flap GMAT)
3 r -�V s FROM TO DIA111I11Q 1 7>�Qa+rss MATERIAL
R n I..
Company Name ,,+J /� �/`1 INNEtt CASING OR TUBING(geothermal elated-leap)
2.Well Construction Permit N: lJ` O'V v L?6(/Z PRIf.OM ro DIAMETER' THIOO4Rsa MATERIAL.
Llaf ell applicable well canunnalon penal*11.e.On Comity,Stara,Variance,614 --I- if` � ) f (t Gj74 V' �h e p
L 11J
3.Well Use(check well use): ft. ft. ha
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Water Supply Well: 17.SCREEN —
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FROM TO DIAMETER SLOT THICENtgg MATE
OAgncultunl OMuoicipaVPublic ft. n MI
°Geothermal(Heating/Cooling Supply) idential Water Supply(single) —
n ft I..
❑Industrial/Commercial Residential Water Supply(shared) IL GROUT •
°irrigation °Wells>100,000GPD FROM TO - MATERIAL IMPMCLMENTMEIHODAAA
Non-Water Supply Well: D R 2-� ft- /1 e t ^ n 1.-ll
- Monitoring - OR Y R. R
/ Y 1 V(� Y
Injection Well: PPr/ Aw ,,
' • °A uiferRech R _ R
9 OGrowrdwaler Remedialion D.SATtD/GRA`ELPACZC[tf no pike ble)
°Aquifer Storage and Recovery °Salinity Barrier - ' ' FROM TO MATERIAL trRIACR.fwr Mrruoi
0 Aquifer Test OStormwater Drainage ft R
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°Experimental Technology ❑Subsidence Control' ft. ft
• °Geothermal(Closed Loop) °Tracer '20.DRILLING LOG(attach addldaaal abeets if aeceuaq)
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remark') FROM TO DtSCRltitpN(ular,b.ri.n,,.wr.de tJpe,Livia abet
R R
4.Date Well(s)Completed: 3-1 / - Well IDI • n 'n .
Sa.. y WellLocation: ft. ft.• I ;M6 l n' tii l
ft. rt.
• Factlity/Owaa Nom.� Facility lDI(if appl•
icable) it ft. :� 0 C V
Phial Address City.and Zip I ft. rt.
lit r t-t. ? • 21.REMARKS/'
County Parcel Identification No.(PIN) _ • •
5b.Latitude and longitude In degrees/nd■ntea/secoads or decimal degrees:
(dwell field,nee lat/long i1 aufficieet) ram`
3/ � � � r .. 22.Ccrtlfic M
�y h ' N 0.6 ' -50 ' �' W 01 L.
f.Is(are)the well(s): {drermanent or °Temporary I I A 1 S4s�wm ofC ' ed'Well,Comracter Date
���111 By tinning this form I herby cuter that the well(:)war(were)canrwued In acconlar
7.Is this a repair to an existing well: °Yes or INo 15A hr..1C 02C:0)00 or'15A1lCAC 02C.0200 Well Construction Standard*and then'this is a repair,fill owl bwn ra well comp action afornaran explain the nature of the of the'sand bah b can prvrided b the wen owner.
•repair miler 021 remarks section or on the bock alibis form.
23.Site diagram or additional well details:
$.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the shone You may usetho back of this page to provide additional well construction
construction,only 1 GW-1 is needed. Ind:cote TOTAL NUMBER of wells ( 'See Over'in Remarks Box).You may also attach additional pages if nett
drilled:
I 24.SUBMITEAL INSTRUCTIONS '
7.Total well depth below land striate: `--`-
Few multiple wells list all depth:((different(example-36200'and:WOO) (It) Submit this GIP-1 within 30 days of well completion per the following:
10.Static water level below to of casi■' r 24a. For. All Wells: Original
Resources (E
If water level a above casing.:las"+"/� /�J6 I I T w (B) Information Processing Unit,1617 k1SC,.Raleigh,NC 276ision of 99-1617
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11.Borehole diameter: � ! b ) 24b.For Iojectlou Wells: Copy to DWR,'Underground
Program,1 G36 MSC,Raleigh,NC Z7699-163 Injection Control
IOW,
Well construction method: R a f a Ill •— A 1- x
[tELLger,:Marx cable,dint omit,etc.)) 24c.For ter Simply
ant department
Geothermal Return Wells:Copy
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tout envnonmen epartment of the county where installed
FOR WATER SUPPLY WELLS ONLY: .
S24d.For Water Wells prodddo¢over 100,000 GPD:Copy to DWR,CCP
13a.Yield(gym) Method of tat • Ai)' Permit 1611 MSC,Raleigh,NC 27699-1611
�j s+
13b.Dish■feetion type: i /°Amorist: .`s/