GW1--05126_Well Construction - GW1_20240827

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WELL CONSTRUCTION RECO (GW- For Internal Use Only: •
1.Well Contractor.Ief motion: Ardtr � •
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14..WATER ZONES
Well Cotttraotor-Naaw r /ROM TO DIaCROTION
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NC Well coae�tar CertificationMusing*eaasiMusing* 15 y. •A U G 2 /
2024 R
C('/ItJ f 1 -�V S 15.OMR CASt1VO(fur waW-caad wells OR LINER(If ap Usable)
PROM • TO
R R T DIAMETER THICRNI33 MAT AL
Company Naas
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1 V 16.INNER CABDVO OR TUBING(ge.th.riaal doted-loop)
1.Well Construction Permit I: ! 'V q q ' �(c� T�1 Hiclottas MATuytL
Vat all applicable well carom-action perorate ft-t (�'QM*Syr. t! ft.
t PROM TO D1AnfsrEli 3 l n i 5�.)/ in /Y I•e(-' )K/
3.Well Use(cheek well use): ft. rt.—I Ia. /
Water Slimily Well: V.SCREEN •
1 �+ \ PROMF TO DIAMETER SLOT SIZE [Matta= M URIA
• ❑Agriculture( Al.... unicipal/Publie ft n la
(Geothermal(Heating/Cooling Supply) esidential Water Supply(single) nnJ ❑IndwtriallCaomercisl Resdential'Watea Supply(shared)
11.GROUT
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❑Itri6lttoip °Wd1a>100,000t7PD PROM TO �. IM7,4( MENfMIrEOD&AMO7 '
Non-Water Supply Well: •
(J/ ft. Z 3 ft.n °Monitoring . OReoov ,� 0 I
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(`' 1 Injection Well: R `t v '�nr( 10
l' J Aquifer n ft. ��
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• ❑A
q Recharge °Chouudwater RemediaUon
❑Aquifer Storage and Recovery O3v fy Barrier D.BAND/ORAYLLPACigt■ hie) • •
moos TO MATERIAL IMtfACIMINf MI ROD
0 Aquifer Test °Stuxmater Drainage ft. ft
°Experimental Technology ❑Subsidence Control ft ft
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• °Oeotheemal(Closed Loop) ❑Tracy 10.DRILLING LOO Weida additional sheeb if necessary)
❑Ocothumal(Heating/Couling Return) ❑Other(explain under N21 Remarks) IRost TO DISCRRi1QN(viler,h.rd.:.t,rah.rk tips,vale sh.,eh
ft.
4.Date Well(s)Completed: 7,3 /.29-tyeu IDI ft- n
a
5a.Well Location: ft. ft
Ratl(110;YI V )6 � ft. ft,
• Fity/Owaer Neese Facility NM(if.ppib w.) ft- R
wt3 5
_cisu4-1,‘ e ILn ek , 12CA . TR. R.
Physkal A ❑l1•and R. ft
� 1� DI 11.REIIIARKB/•
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ll(J�J
County Pavel ldadilcatiaa No.(PIN) _ •
5b.Latitude and longitude In degreea/oienteshecomds or decimal degrees:
(if well field,ane liVbng it sufficient) — �r'' (J
12-Certification: kira
C
,v«' 7 N �Q 5 5 id'' IY 1•,�ry
f.Is(are)the well(s): G7pernuueet• or °Temporary ' 91aTM�e bf Certified•�VeU Cor,hau,r a
���lll !2G� Doe
`` By signing this force,I hereby co rthy that the well(,)was(were)comuacted in accordance
7.Is this a repair to as existing well: ❑Yes or iNo LiAMAC 02C:0100 or'IJA r�1C 02C.0100 Weil Cenutrre elan Si.da„r,.id Weal e
If this is a wolf;fill o_known well coma wri on afforanwlon explain the nature of the 9/this record has been pwt1ded it the wed owner.
'repair order Ill reworks section or on the back of this forms.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the Jeme You may use the back of this page to provide additional well construction in
construction,only 1 OW-1 is nodded Indicate TOTAL NUMBER of wells (add'See Over in Rbniarks Box).You may also attach additional pages if recess
drilled:
24.SUBMITTAL INSTRUCTIONS
F Total weBdepptt haMw land aortae*: S•21)l (R)
"r"I°l' ll e/ram►u�w(lawlpre-!@]o0'.nd;(�Ipp) Submit this GW-1 within 30 days of well completion�� P per the following:
10.Static water level below lop otudmg: (R) 14a. For All Wells: Original form to Division of Water Resources (DMrwwar laved Is whom aseheE.se-+—/! Information Processing Unit,1617 MSC,.Rdn i gh,NC 27699-1617 ,
w
11.Borehole dller; gym) 146.For Ljectlon Well,: Copy to DWR Un•
derground Injection Control(II
j, a rProgram,1636 MSC,Raleigh,NC 27699-1636
12.well comotrmelb Rci • _m noelhod: Air
(i.e.•na•r•Max oils,direct pet*me.) 14c.For Water Supply and Open-Loop Geothenuai Return Wells:Copy to
county environmental boalth I partment ot me county
where iitsa
• FOR WATZR SUPPLY WILLS ONLY: .
14d.For Water Wells rodldde;over 100,000 GPD:Copy to DWR,CCPC
13a.Yield(ono) I O I 1 Matbd of last . Air • Permit Program,1611 MSC,Raleigh,NC 276i99-16I I
13k jp Dii.Mem type: Ps ` `'l Ampere q I4/ _ - t t