GW1--05063_Well Construction - GW1_20240827

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WELL CONSTRUCTION.RECO (GW-1) For Internal Use Only: .
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1.Well Coatrectanlaforatio�• •
524,114tit.... .
m
r 8'Y •14.WATER ZONIS
Were CoatraetecNaa» 50,f
.. I FROM TO DL•Qn`'r7pN
(d
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.• L-1-
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Is• �1 ft.. /t 41p�1D R
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NC Well Contractor Certification Number • _
CA
,-- i / IS.OUTER CASING(for am W-cased wells OR LINER(If up Gable)
FROM 5 ro tit-ty S - �MW1f
TO DiTlQ iffiaQ(C93 i MA't'LNAL
Company Nome R rt. ht 1
3D �j(�, 1 f.INNER CASING
ING OR TUBING(eeothvmal doted-loq)
2.Well Construction *: t/•
MOM T DIAMLrrR MOMS! MATUTAL
List all applkabk well cautrwalon perdu(Lc(AC Corny.Stale,Variance etc) f I t` ,3'D R 51$1 (a' 7T 1 1 c„
3.Well Use(cheek well use): ft. ft. •
la. pl..:
Water Supply Well: .17.SCREEN
MOM TO DIAMITIR SLOT SIZZ THICKNItS3 MATE
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❑Agricultural •❑Municipel/Public • R. ft ._ M.
❑Geotheal(Heating/Cooling Supply) idential Water Supply(single) `
rm ft. ft. la..
❑Industrial/Commercial identiil Water Supply(shared) is.GROUT — _—
❑Irrigatio(t ❑Wells>100,000(3PD FROM TO MA fatrtwCDKUNf METHOD&AM
Non-Water Supply Well: v ft- 2 3 R
• ❑Monitoeing •
1 (- ❑Recovery ft ft Injection Well:❑A �DYftd►w( a�Y� v�
Aquifer ft- rt.9 Be ❑Groundwater Remediation
uiferSto IC.SAND/GRAVELPACKcifappliable)
❑A q rage and Recovery ❑Salinity Barrier . FROM TO_ MATERIAL faRIAciarzur Karam
❑Aquifer Test ❑StormwaterDrainage rt. rt.
❑Experimental Technology ❑Subsidence Controi R n•
• ()Geothermal(Closed Loop) ❑Tracer '20.DRILLING IAO(attach addltloaal sheet,if necessary)
❑Geothermal(Heating/Couling Return) ❑Other(explain under 021 Remarks) !MOM ft. DISCRRIIQN(oiler,r.rt.ae,»wrack sere,pan she,
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ft. ft.d.Date Well(s)Completed: (J �5' Well ID# • ft. 'It.
Sa. ellLocatloe:
11w 1 ornrL
f� �m1 -�V �Gt SI U•a-t.' i ftft.ft. ft• FacilityaNaar I /
Facility BM(if appiieabia) ft. ft
US 77A ' '
_ I s 44 7t. 70 c Rd . -ft. - R
Physical Address,City,and Zip ft. ft
/A$ 11.REMARKS
Com Parcel Identification No.(PIN)
5b.Latitude and longitude la degrea/minntesfseconds or decimal degrees:
(if well field,ooe lat/loep is sufficient) eel
22.C atv�'t
3L' GI I ' 3" N 8 I.' 3 s' `3 3 ' • w 4/� (.y
6.Is(are)the well(s): idPermaaent or ❑Temporary C�D Sites ofCertifiaf•�rell Cootncmr `/ /Z
���lll J Date
7.Is this a repair to■■existingwell: ❑Ya or By signing this form,1hserebysersfyThorthewells)was(sere)constructed inaaconion
No 1SAMAC 01C.0110 cr'13A NC'AC 02C.0200 Well Cpnutrvctton Standards and that
If this/s a repair,jilt owl brown well construction Information
M/ join the nature of elk of its record has ba rt 1omYded b the Will owntr
'repolr ruder 121 rratorb section or on the back q/ahls form. •
23.Site diagram or additional well details:
I.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the SWIM You may use the beck of this page to provide additional well construction
construction,only 1 OW-1 is needed Indicate TOTAL NUMBER of wells (add'See eve?in Rdr:arks Box).You mayalso attach additional drilled: ) pages if Rees
24.SUBMITTAL INSTRUCTIONS ,
9.Total well depth below land surface: (ft.)
For multiple wells list all depths Ifdierent(seample-3@p00'aid;gm) Submit this GW-1 within 30 days of well completion
p per the following:
10.Static water level below top of casing: 6 AIL) 24a. For All Welk: Original form to Division of Water Resources (D
.fwater level is above caslnL:oc-4- ` a Information Processing Unit,1617 MSC,Rdeigh,NC 27699-1617
11.Borehole diameter: 6i 41n.) 24b.For Iojectloa Wells:Copy to DWR Underground
Program,•
1636 MSC, Injection Control
12.Well construction method: Co ±'a_r� • _ Raleigh.NC 27699-1636
) V
(Le•super,rotary,cable,direct posh,etc.) 21c.For Water er Supply and Open-Loop Geothermal Return Wells:Copy I
county eanronmukai health department of the county pie metalled
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• FOR WATER SUPPLY WELLS ONLY: .
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• 24d.For Water Wells prodeclr¢over 100,000 GPD:Copy to DWR,CCP(
13a.Yield(rpm) Method of tat )' Permit Program,1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: il'i Amount •w .