GW1--05064_Well Construction - GW1_20240827

WELL CO RUCTION RE 0 (G W 11 For Internal Use Only:
ytlyq�1.Well Contrae g
ey�a� • •14.0 WATER WNIS
Well ContractorN G /J FRM TO DL7C1lIP11ON
I...5_l 7 1 fi p p ft.
e ' 51-LOrr.
It R.
NC Weil Contractor Certification Number
' ,r 15.OUTER CASINO(for wrath-used welt)OR LINER(If ap.liable)
. ,-, _ 1 �� r!`-y-�}� .vs
FROM - - TO _ DIAMLTIR TffiC1OtL7S MA'f'E1llAL
Ch/!L/ l/ l , 1 ft. R hi.
Company Name 3 36
tt-3 16.INNER CASIIIG OR TUBING(geothermal elTI e ed-loop)
2.Well Construction Permit N: FROM TO DIAEIEIt iffi(7OtesS MATERIAL
List all applicable well construction permit:(I.e.U)C Comfy,Sick Variance,art.) I rt• ]�I� R `JC'lt/ 1. �/,e f�
3.Well Use(check well use): rt. ✓ rt. //O In. I
Water Supply Well: 47.SCREEN
FROM TO DIAMETER SLOT81LE THICKNESS MATERL
❑Agricultural ipel/Public rt. rt, hi.
❑Geothermal(Heating/Cooling Supply) esidentiel Water Supply(single)
ft. ft. Ie.
❑Industr m ial/Comercial esidential Water Supply(shared) 18.GROUT
Olrrigation °Wells>100,000 GPD FROM TO - MA CMILACTMINT METHOD&AMO
Non-Water Supply Well: U ft. Z,3 ft. C at
d'I r;)/.
❑Monitoring °Recovery Itfft. L ��
Injection Well: - �/d n/( D(ti-y.?4
R. ft.CIAquifer Recharge OOroundwater Remedia(ion .
19.SAND/GRAVEL PACK(if ap plies ble)
❑Aquifer Storage and Recovery °Salinity Barrier - FROM TO _ MATERIAL I MY ACEMINT mrrnoD
°Aquifer Test OStormwater Drainage rt. rt.
❑Experimental Technology °Subsidence Control It. ft.
• °Geothermal(Closed Loop) °Tracer '20.DRILLING LOG(attach additional sheets if necessary)
°Geothermal(Heating/Cooling Return) OOtlter(explain under t/21 Remarks) FROM TO r DESCRTTIIQN(icier,hardens,',Wreck type,patty are,et
It. ft.
4.Date Well(s)Completed: 7.2). i A}+e11IDN • ft. rt.
5a.Well Location: ft rt
se h 3i72 art). rt. rt. AUG 2
• Facility/Owner Nam. Facility ID.(if applicable) ft. R.
To 1) B e h �v • 1)- t v d • ,n - l3,`;(:;
Physical nom tzy,.sd zip R. It
21.REMARKS/!
County/ Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(dwell field,one Ittneng it sufficient)
3 I 3 N 7 �j /� 22.Certk l a
i
,4„,
6.Is(are)the well(s): Permaeeet or °Temporary 3 / Signature ofC • isii,,Vell Contractor Dote '
`,
By signing this form,l hereby certify thew the wells)was(were)constructed in occordanc,
7.Is this a repair to an existing well: ❑Yes or 1No ISANCAC 02C:010(1 or•ISANCAC 02C.0200 Well Connnrcnon Standards and that a
If this to a repair,fill out known well mown action information explain the mime of the o(ihts record has been prvrided wo the 1raA owner
repair ender H/remark:section or on the beck of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the none You may use the beck of this page to provide additional well construction it
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Rdniarks Box).You may also attach additional pages if necesi
drilled:
(R)
12_D 14.SUBMITTAL INSTRUCTIONS
I
9.Total well depth below land surface: ` -
For multiple wells list all depths iifdii different(example-3@200'an.2®10i) Submit this GW-1 within 30 days of well completio■per the following:
10.Static water level below top of casing: I D.
•f 24a. For All Wells: Original form to Division of Water Resources (DV
If water level is above eosml,:ate'+-/�_ �/l 3J ! ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
•
II.Borehole diameter: ` (in.) 146.For Injection Wells: to DWR,
Copy Underground Injection Control(I
l l a f a rt- .� A 1 Program,1 G36 MSC,Raleigh,NC 27699-1636
12.Well construction method: •
('. . set,rotary,cable,direct push,eta.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to
to au p
county environmental health department of the county where installed
• FOR WATER SUPPLY WELLS ONLY:
• I 24d.For Water Wells predating over 100,000 GPD:Copy to DWR,CCPC
13a.Yield(gpm) J Method of test: r Permit Program,1611 MSC,Raleigh,NC 27699-1611
1 µ
13b.Disinfection type: l Amount: es v✓ '