GW1--05633_Well Construction - GW1_20240916

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' WELL CONSTRUCTION RECO ^.(GW-1) For Internal Use Only:
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1.Well Centric r.Informa o• filifOrA •
•14.WATER ZONES I I ••
wanContr.aorN me • PROM TO t DISCIWT1ON •
353' Gov*� 3zo;,
fc m
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NC Well ContractorCatifiatioaNnmbrr
15.OUTER CASING`(for multi-aced wells OR LINER orals Gable)
Ci.'i 13 r[) -e_V$ . PROM • C ,•r0 , DLtllsri'R TBICIWsmimosasMAamRIAI. _
CompanyNEP° •
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^1 ^ 7s 16.INNER CASING OR TUBING R canal doled=loop)
2.Well Construction Permit#: )V'2 h amens TO • r�c�yss ierliluwL • '•
Lid all applicable Ndi eanrnuctlon permits(Le.AJC o+?uy,State.Varlamce.etc) 1. ft. 1 lit td
3.Well Use(check well use):
Water Supply Well: l7.SCREEN
• °A cultrtiel PROM TO r 'DLeMIr=R SLOTSI= marines MATIR AL
gn 'l]Municipal/Public ft. • fk - in.
°Geothermal(hheating/Cooling Supply) identical Water Supply(single) ft. • ' '
OladuSt riaUCaamnemial I 1O
�idential'Water Supply(Shared)
is.GROUT • , ; 1 _
o hrgatio(u • °Wells>100,000GPD • PROM : TO • MA F1li<LACIIIS1rrasIBODaAMOutr
O Mani Non-Water Supply Well: �( ft. T/S a e_•T. M•X 1 Q
g •°Kara Do t
o«y ' ,� .
Injection Well: ,r t
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OAquiferRecharge °GroundwaterRemediation •
It ' . ft 11��
°Aquifer Storage and Recovery °Snluti Harrier 19.SAND/GRAY=PACK(dappIJable) •
ty PROM TO. MATIRIAL IUttIAC01t1NTKEIR0D
aAquiferTest DStomtwaterDrainage • ' ft tt
°Experimental Technology . °Subsidence Conti ft•
• °Geothermal(Closed Loop) °Tracer •20.DRiLLINGLOG(attach additional'hub ifneeeuarr)
OGeothesmal(featinglCoo ling Return) °Other(explain u=der#21Remarks). PROM': TO • asscn>PTION(c.i.r:bal.ea,..ar,.ercyoe,Ra:,o:,rk)
p '` ft 1R
4.Date Well(s)Completed: -f-T•• ' Well JD#
5a.Well Location: (t ft
• Lo. a jV1c)orG ' . ..
. Facility Name •Facility IDI(ifapplicable) ft .. !ft 1: ,..t,.K '
fiFF 1. t:'7f74''
Physical Address,City.and 7.4 , lit it
SL1 rn') 21.REPdARKsI � ..Frr.' •s,f:.
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County Parcel ldeotifiatiaallo.(PIN) t`�: ,u'a_r:�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: !s
dwell geld,one let/long iY •
.� t 7 r sufficient) r 22.Certification: _ _
w
6.Ib(are)the well(s):X(Petmanent• or ['Temporaryi Sfgnabub well
Date
7.Ist6isarepairtoaaexlistiagwelL• °Yes .or .�( Bp+tgningthtsjomi.IheiebyeertAy 02C.ew0A(r),mr(noc)eairwuedtnaoeattleeenlrh
1 this le aJ�'No ISAUCtC 02C:0100 orWIliCIC 02C.0200 Well CpnrttuctIon Standards and that o copy
f repair, out well emupuenoa tnformatton explain the nature ethe elks mzeordlarl been Provided le'bawd'omen' •repair under 121 remark:section pi.on the back ef AI:form.
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 GW.1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'm Rir:sria Box).You may also attach additional pages if nGXssamy.
drilled: •
• 24.SUBMITTAL INSTRUCTIONS " ' .
9.Total well depth below land unlace: 3 lb (n) '
"ormulaple wells Lit all depths("different(cram p/e-3@200,surd l@),►Op) Submit this GW-1 within 30 daisof well completion
p per the following.
10.Static water level below top of casing: a ( ) 24a. For MI Wells: ,Original form to Division of Water Resources(DWR),
f ter level':*choirs as r we+'/ (/U R Information humming Unit 1617 MSC,Raleigh,NC 27699-1617 .•.
11.Borehole diameter: CO` O (tp.) 246.For Injection We'lls:Copy to DWR,
Underground Injection Control(IUC)
i� a+ a Ili
Program,1636 MSC;Raleigh,NC 27699-1636 _
12.welt construction method: '.. '[� u • '
(ie.Welt
rotarx cable,dkoctpwb etc.) • 1 "!r.! r 24a For Water Supply and Open-Loop Geotherioai Retain Wells:
CopY county environmetttel health department of the county where installed to the
• FOR WATER SUPPLY WELLSONLY: • . '
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24d.For Water Wells prodadnc over 100,000 GPD:Copy to DWR,CCPCUA
13a.`Yleld(gpm) I O Method of test 'A i.r '' P Program,1611 MSC,Raleigh,NC27699-1611
136.'Disinfectioa types
_ , . Amoral: /0'•p✓ i,
'1., •Fenn rr{Y. ' �` .