GW1--05299_Well Construction - GW1_20240906

1.Well Contractor Information: •
Well Contractorldnme / Ga 4/I �T� �'!�'": 14.-WAT ER ZONFg
[.J / �oM To t>Escnrt g nox
1fO�� R.. ft. o
NC
Well Connector Certification Number ft. rt.
!/. Iv , IS.OUTER CASING for multi-awed walls OR LINER a..feeble
TO l
Company Name /��- FROST ' ft. (DIAMETER THICKNESS ?uraaWL
it /, in. C /0 2.Well Construction Permit#:
List all applicable well carrotnrcfian ce.etc.)�f 9 16 INNER CASING OR TUNC :eo a `e( J �C
FR01 TO DT tb al closed-lao,
permits tie.UIC,Comuy,Stale.Yarlan R. Txlelavass MAT7tRIA1
ft. in.
- 3.Well Use(check well use):
R.
Water Supply Well: IT:SCRItBN
❑AgflCUltlttal ❑Nitric" FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Geothermal rpaUPuatetn.
(Heating/Cooling Supply) Mc sidential Water Supply(single)
❑IndustrialCommercial ❑Residential Water Supply(shared) to �
❑Uri anon 10.GROUT
❑Wells>100 000 GPD FROM17 T O
Non-Water Supply WelT EMPLACEMENT ACEMENrygTkOD&AMOUNT
❑Monitoring ORecovery R. R. �" 7
Injec on WeI1: R. R.
❑Aquifer Recharge ❑Groundwater Remedintion It, it.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19'st /GRAVEL PACK fa 'dlcable
OAgoiferTest, FROM TO MATERIAL . EMPLACEMENT METHOD
❑Stormwater Drainage fr. 2
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) R.
❑Tracer 20.DRILLING LOG(attach additional sheers 1f necessa
❑Geothermal(Hcating/Cooling Return) ❑Other(explain under#2I Remarks) M—. TO DI3SCRD'T•ION{eu1,r,tmntn
ft. it m,soWroch inljesdn
ma etc)
4.Date Well(s)Completed 21_4 a Well IBtx Vr._,e404/ G
/oft. 35ft.
,_,. ii ft. ft.
S .W I Location; J)*rei
ril LCct
�(c �i 5 � yy n �Facility/Owner Name `^) / 30 0 -‘
Faciliy applicable) " tL n;
saes. Grover if'4 �/� ,^, _ //,�, 1.:f ___7__--__-__,._.,
i I Address,City,and Zip
I. .36'1L 30 - _ ozY
Zl.RBMARK3.
County Parcel Identification No.(PIN) I r OOP;44iC,"
5b.Latitude and longitude in degrees/minntes/seconds or decimal degrees:
Orwell field,one ledlong is sufficient)
7 ? Ll� g i N S Q a 3 a / 5/ W 22.Certification:
6.fs(are)the well(s) nnent or ❑Temporary ed Well Con �- a,`� `
Date
nn
7.Is this a repair to an existing well; ❑Yes or ) signing flitform.I harrow certlfv titer the rwell(s)uas(were)conruucred in accordance with
Obis is a repair,fill out known well contuvetloa i formation and explain the nature of the of th�record has been provided to the well owner.
CoN aan Srandardr and tiler a copy
, repair under#2l remarks section or on he back of this farm.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 0
9.Total well depth below land surface: 3 24.SUBMITTAL INSTRUCTIONS
For multiple wells list all depths if-different nd ( )ep (example-3®2QQ'and 1®IQU� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of easing: Q 24a. For All Wells: Original form to Division of Water Resources
( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level Is above casing use"T (DWR),
II.Borehole diameter: (, �f (in.) 24b.For Injection Wells: Copy to DWR,�/ Underground Injection Control(IUC)
/� � Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /�D a/'i.e.auger,rotary,cable,direct push:etc) / 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
(�' For Water Wells roducin over ID OD GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) . Method of test: A; r Permit gram,1 11 MSC,Ralei NC 27699-1611
13b.Disinfection type:/4 %/471 Amount '3 g;n 1- -