GW1--05125_Well Construction - GW1_20240827

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WELL CONSTRUCTION RECO GW-11 For Internal Use Only: .
1.We f ,., t ere tot a•
?eihn,
d r
•14.WATER ZONES
Well Contractor-Name PROM a ft. TO
DDCRR770N
35 �" •
IL f.
NC Well Contractor Certification Numbs IS.OUTER CA5IJ (fir milli-used wells OR LINER Of applicable)
/'. J 5 r�\`�-�.-e v$ FROM • - TO DIATrII'iR THIQQ(L� I MA'f'AliA1.
CiV It l./ l R• IL la.
Company Name _
If.INNER CASING OR TUBING((mlbermal dated-loop)
•2 Well Construction Permit A: FROM TO .DIAMm R THICK:MSS MATIAL4..
List all applicable well constructton permits(re.f11C,Courtly,Slate,naivetes.etc.) —/—/ ft. 63 1t f j) la � ll ` pi-.--.-
+_/'
3.Well Use(check well use): 0q 70 W R. •
_ rt. • I.. h `
Water Slimily Well: V.SCREEN
FROM TO DIAMZTZR I SLOT FIZZ I nilacrISS 1 MATta
• ❑Agricultural 'OMunicipal/Public R a. in
❑Geothermal(Heating/Cooling Supply) dential Water Supply(single) ` -
n n. in.'
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Olndustrial/Commercial Residentid Water Supply(shared) I e.GROUT
Glrrigatio(t ❑Wdb>100,000 GPD FROM TO MA IMP LACIMLNTMIrBOD&AM
Non-Water Supply Well: U R Z 1— �qr PA 4. --1 e„(
• ❑Monitoring OR
' Injection Well: POr;' n 11 4./
• ❑Aquifer Recharge OGr undwater Remediation n ft.
OA uiferandvSA.I.1D/GRAVfLPACK(If■ppiluble)
q Storage Recovery ❑SalinityBrrier - FROM TO _ MATERIAL IMFLACVMINTMentor
❑Aquifer Test ❑StormwaletDrainage ft. it
OBxperimentrd Technology ❑Subsidence Control' ft. ft. •
• ❑Geothermal(Closed Loop) ❑Tracer '20.DRILLII'IG LOG jattath additional sheets if Necessary)
❑Geothermal(Heating/Cooling Return) OOBher(explain under N21 Remarks) FROM TO Dt5e7tII'I1QN(mkt;herd BM,',Wreck lieu Hain Me.
f. R
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4.Date Wells)Completed: !7 13- 2,‘ Well JD ft. 'tt .
5a.Well Location: it ft
• Fael ity/ aer�Ow Nara Fatality ID/(if applicable) ft ft.
Physical
�Address,City.mad Zip / - ft. — ft.`� a Cve.— • 2L REMARKS/ =
County Parcel Identification No.(PIN) •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ►.
� L,
(if well field one IaUloea u sufficient) 404.1
�'3 12.Cer lion
(� / 7 , -3‘ N V ' :53" y7- W
• - IS---2
b.Is(ire)the wells): Permanent or OTemporary /�2 0• Sites ofCatiSed•Well Contraaur Dato
By signing this form,I hereby ceriO,thot the well(a)was(were)constructed in accordant
7.Is this a repair to an existing well: ❑Yes or No ISAhCAC 02C:010 0 or'IJANCIC 02C.0100 Well Cptutrucoon Siondardt and that
if this li a repair,fIll out known well construction li formation at aaphein the twMie of the of ens record has bees provided so the wall owner.'repair under 121 remarks section or on the back of this f 6rm.
13.Site diagram or additional well details:
I.For Geoprobe/DPT or Closed-Loop Geothermal Wells laving the Shane You may use the back of this pogo to provide additional well construction i
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Re carks Box).You may also attach additional pages if mr'
drilled:
24.SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: (�)
For multiple wells list all depths differentf (example-3®100'and 1®/00� Submit this OW-1 within 30 days of well completion
p per the following:
10.Static water level below top of casing/ (R•) 24a. For All Wells: Original form to Division of Water Resources (D'
1fwaterlevel is above caring;:are-+-/_ /tJ Information Processing Unit,1617 MSC,.Raleigh,NC 27699-1617 •
11.Borehole diameter: 6o / 8 en.) 24h.For Injection Wells; Copy to DWI,U End Injection•
Program,1 636 MSC,Raleigh,NC 27699-1636 construction•
12.Welt construction method: �a {�•f'(.l ._ 1�1 I.
cm rotary,able,direct push,eto.) ll l s 24e For Water Supply and Open-Loop Geothermal Return Wells;Copy t
county eaviromncncal health department of the county what installed
FOR WATER SUPPLY WELLS ONLY: -
24d.For Water Wells prodedn;over 100,000 GPD;Copy to DWR,CCP(
13a.Yield(6Pm) 2 0 Method of test ..A j r • Permit Program,1611 MSC,Raleigh,NC 27699-1611
(t
13b.Disinfection type: 771 Amount k is---