GW1--05634_Well Construction - GW1_20240916

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WELL CONSTRUCTION RECO • ,(GW--11 For Internal Use Only .
-1 Well Con• etor•Iaro lion•
�'t� 14:WATER7ANi51 I ' - . , .
PROM TO t I Dxscurlilott
3.53 s:
•
. !ao f°• 320
NC Well Contrietor Cestifieation Number
15.OUTER CASINO(for multi-need'nib OR LINER Ora Gable) •,
PROM - • -TO ' !<. DIAMETER , TmciQ s • MA
`/ 16.OMER CASING OR TIMING(geothermal droll-leap) •
2:wen Conetractlon permit#: C ' fJ ) (p d 3 PROM • TO •DIAMMER THICKNESS • MATERIAL.
List all app(laabla wr•!(canimualon perndti 0.e. 'gamy,State,Valiance.eft.) .fl.. n. 60 ''1t ,f�� In
• - 3.Well Use(ehet:kwell we): • n -
Water Supply Well: 17.SCREEN r, • • • '
• OA Cultmel , PROM TO •I: DIAMETER SLOT SIZE THICGIPSS MATERIAL
tan '. , `OMtmicipal/Public n !e _ Ia
•
"Geothemal(Heating/Cooling Supply) idential Water Supply(singlo) ,
- oIadustrial/Commnciid O' identiel'Water Supply(shared) '
1#.GROUT-
Ohngatioo .. ' . °Wells>100.000GPD -. PROM.. .TO = MA EMZIAOMENTMETHOD&AMOUN1
Non-Water Supply Well:. . . l n • n [AlDMoniforing °Recovery �/ �i3j (1';�C,*,�,
tt. R w._ L .
Injection Well: , • .,. I JDY 7 /� i(
• OAquiferRecharge_ ,. OGro mdwaterRemedialion R fL /
geandRxway` OSalinityBarrier o�SIr/ORAVL'LYACR Of OAquiferStosa
MATERNAL . ` sairuczaturrMpaon
OAquiferTeat OStormweterDrainage Et R
', OExperiinental Technology• OSubsidmoo Control ' n • . -
OGeothermal(Closed hoop) OTraar
• '20.DRILLING LOG(attach additional sheen if accusers)
OGeathermal(lieatingACoolingRcturn) • °Other(explain under fl21 Remarks) `PROM • To ' ,. „ xsOus'fQN(at.r,balms.,!wrec !y .R,:.te. l
D
4.Date�Vell(a)Completed / J� Well ID# n tt.
5a.well Loea6on: :n rf
• ' �`"
1 . ..ft f ,y ®®
',J t t1/\IA - v! • . Ir.'''
FaeihtyOnnerN.mo Facility 1D#(if applicable) it! {n' SEP 7 A .
Pbysid Addmee,(Sts:.od Zip ft. t r _ vx` `..
21.1tEMAR�IS( f Qri�i c..1;t d:7,4;.
. •,. Yamelldwti@atioallo.(PiN)
5b.Latitude and longitude in degreesfminntesf.econds or decimal degrees: ,
(if well Geld,mein/long iY eulfieiaot) 22.Certifi tion: 1,,A J_• .
6:Is(are)the weil(a): ermanent .or °Temporary • 0 r SiSaatw ofCatifisrd Wdl,Coalssctoc ,
9 d By n this
7.Is this a repair to an existing well: °Yes or No• ISA C o2C A!o O C C.02001(poll C��)constructed
m ed hi w Ceerg 1f this Ira repair,fit1 wrt ktotm xrll eanrtruofon omatlon a o as recmd/wr been Oattrwefon Statidmdr and that a• ',
• • under#21 ratarb opiate the nattt>Y.ofths f prvrlded M dawn aanrr•''. •• xP?!r � rapfott or the baekofrhlrfomr. ,.. . ,
23.Site diagram or additional well details: ' •
, 8.For Geoprobe/DPT or•
Closed-Loop Geothermal Wells having the stare 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 Rd b Bo
x).You may also attachpages ifnecessary•
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2,•O (1ti)• I�
• Fortaultple wdlr!!et all depth:((different"maple-3®j00'and 2�� Submit this OW 1 within 30 days of well completionthe followm P per B';
10.Static water level below top of casing:g / Z O • 24a. For All Wells: O (DWR),
(R) 1 ti�inal form to Division of Waller Resmrrcea IfwaterlesW fr above taorhty lira'+CJ ,i lnfonnation Process' p .
!!/ Processing ntt;1617 bLSC,Raleigh,NC 27699-1617,
. 11.Borehole diameter p•) 246.For injection Mello:Copy to D
W-I,Undergrou d Injection Control(1UC)
1j Program, MSC,Raleigh,NC 27699-1636
12.Welk eoustructiunmethod: 'CS 1 a r(•t •_ "
—
• s(r.e anus,minx cable,direct l . f r. 24e.For Water Sop ,and Open-Loop Geotberinal Return Welt:Copy to the
p ) ply
• . county environmental health departant of the county where installed,
•
, -. . FOR WATER SUl'PLY WELLS ONLY: _ : ''
13a Yield.(ipm) ••,• S . 24d.Fo Water Wells produdti¢over 100,000 GPD:Copy to DW CC
R, PC1)A
Method of teat: `�i r m sram.1611 MSC,Raleigh,NC 2769971611
• 13b.Disinfection type:_ ) . - Amouut: O Gti i '