GW1--05636_Well Construction - GW1_20240916

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WELLCONSTRUGTIONRECO (GW-11 '
For Internal Use Only:
' 1.Well Contras ormition: • • •
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14.WATERZONItS 9 i
WellCoatreaorN AtOM TO Y 1 DtSCADRION
ft. 1R, .
NC well Contraetar Certification Number :
15.OUTER CASING(for mold-used welt OR LINER(if my Gnble) -•'
•cVi✓= l3 rU L h-�v$•
FROMfp y 51 DrALriR MATERW,
R R � T!
-/.Gj VV 16.INNER CASING OR TUBING(geothermal dosed-lop) •
2.Well ConstrnctionPermit#: - .' PROM TO •BURIN/TR: •f�ows�s M&TLRIAL.
-Lie all applicable well eaunodion permits(Le.WC County,3'ate.Var atee,ere)
'•3..Well Ilse(check well nee):,. • R • 'i io
Water Sa
pPb Well: •
.17.SCREiN• .:
Munk PROM TO II iDIAMUI=It• SLrtTSIZE THIaai ss MATeRIAL
, . • °Agricultural • ,, ipal/Public
°Geothermal ft R�, in.
(Heating/Cooling Supply) O widential Water Supply(single) . R • R;` : • fa.'
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Olndustrial/Commereial eatitd'Water Supply(Ahmed) le.GROUT '
°Irrigation ; •. • OWells>100,000 GPD • PROM TO. MATZEL4L -vaticIMgNr•Banton&AMMO
' ' Non-Water Supply Well:- .• ; - - . - -- •..-:: _ itR
: 7. • .
' - °Monitoring •ORecwery '
• Injection Well:
°A uiferRec6 • R R
9 • °Groundwater Remedintion
OAquiferStorageandRecovery °Salons Btrerier 19.SAND/GROLLPACKCdappllesble) : . -
ty• /ROM • TO 1 " MATERIAL LACrM=NTMUIBOD •-
OAquiferTeat OStormwaterDrainage ► R. 'R
OFsxperimentel Technology • OSubsideace , -Control n R � �.
°Geothermal(Closed Loop) •• • °Tracer , • •, t -
10.DRILLINGLOG(attach additional sbeeb if neeewaq)
°Geothermal(Heating/CoofmgRetirm) °Other(explain under#21Remarks). FROM TO , Dtcc ••ON(nbr,r.rday.usVnclarwe,t,,;,,ta,• ,
4-Date Wells)Completed: 9 /(J'2) Well ID# • tt' . IL
Sa.Well ovation: R
6 rch . /4) - - R ,R 4h !ire'd A'ew �/d •., ..
• Fa 'ty/OwnerNamo Facility Eh"(xfappGeabla) n 'R
sf Hate 5 G.C.Li t,' ,;R SEP '1', u...,:202 :
physical)/A//.///•/ CityandZip fa
t•—k7 _ft. :ft. 1� n• •r.- ; ',.
'iLREMARRS!
County - _ .. , '
Parcel •
Ideotifieatraallo.(PM)
56.Latitude and longitude in degrees/miautes/aeconds or decimal degrees: ,
(ifwell Sold,Oise let/long U ndBeieat f
a 22.Certification: p l
3/' ,oil) ' `t,N 01 ' '(' ,5 s ' W -� -' ., •
1171
• 6.Is(are)the well(s):VPermanent or OTemporaq / . Q /• S•_" . .f a -•'1, _ .- Date_. -
Py+ldning !a Iharby cenNe this S towell(a Cons(e e)coat ea d acnordmnawUh
7.Is this a repair to as existing well °Yes or �JNo• 1SAI4CAC 0 C:0100 or XJJ11iAC4C OIC.02001re11 CpamucNon Srasdardr atd that a copy
lfthlsIra repair,fill out btoxr{well cv,,,# a,Worinatlon a dexplaht the naNn.oflhe oflMs rewnfluv beat to the well airier,
'repair under IV remarks section or on the back of hisfom, _
23,Site diagram or additional well details: . : ''•-
. 8.For Geoprobe/DPT or Qoaea-Loop Geothermal Wells having the atme You may use the back of this page to provide additional well construction info'
. Construction,only 1 GW I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Rt arla Box).You may also attach additional pages ifnecessaiy.• drilled:
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: 24.SUBMTITAL]N .STRUCTIONS ' . •
9.Total well depth below land surface: (a) is =
`Far multiple wells list all depths rfdpoeat(euanp/e-3 f#700•a,d?®1007 . Submit this GW-1 within 30 days of well completion per the following: •
: . 10.Static water level below top of casing: 'R 24a. For,All Wells: ,Original form to Division of Water Resources (DWR),
lfwrterlevells above corefeAre-+- I/ ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 • '"--
" m
11.Borehole diameter. • , 6` -. .(in.) - 246.For Injection Wells:Copy to DWR,Underground Injection
Progran,1636 MSC,Raleigh,NC 27699-1636 •-• ' ' ; Coatiol(IUC)
, - 12.Welt construction method: .' -r 6 T'a.r-l • J�1 r . . .
(i.e.auger, +R(Tahiti,direct pink ate.) . l ` - 24c.For minter Suppi and Open-Loop Geothermal Retara Well,:
county environmental health department of the coup where Y to the
FOR WATRR SUPPLY WELLS ONLY: ' - •• , county installed -
. 240.For Water Well prodddn over 100,000 GPD:
CoPy 13a.Yield(gpm) ' .Method of test: ' i r Penult g�.1611 MSC,Rnleig6,NC 27G99-1611 ; to Dom'CCPCUA
I.
131i.Disinfection type: Amonnt: • - • •
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