GW1--05638_Well Construction - GW1_20240916

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WELL CONSTRUCTION IZECO (GW-1) For Internal Use Only:
1.well Contra ormation: . .
5241444,.
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• • •14.WATER ZONES I' 'r . . •
Well Con. .
tractor. cyt,i0, PROM TO 1 .•DLSCRIFTI0N
5q7 4 �5d� 3R • • .. ,
rlc wen teror catifiatian Number ;
15.OUTER CASING(for mold-cued welt OR LINER Of■ Sable)
53 rc> -LV$ PROM • -TO a DMJ1ZTZ 7m M
CKRZSS ATICRIAL
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Company Name • . , , :
/1
• • • ��]1 Li
- 1 // 16•INNER CASING OR TUBING(geothermal elostd-loop) '
2.Well Construction Permit 1 !. �'" • PROM TO •DIAMsrzR' TIRCIWtS9.• MArnrat, •
LLt aBappllaable well c o. eaton permits(Le.UIC,Corm%State,Pmimrce,ere) fL ILI 9,`tn. iZir'et:.. .7. •
3.Well Use(check well use): - ft:' tt�` to
Water SuppiyWell: - 47,SCREEN - • a
- PROM i TO DMr' rvt I sums'r 6 I TSIC OS MATZRW.
OAgriculdind ''.' ' OMunrcipal/Public f (z rt. in.
OCTEOthtrmal(lleetmt/r.001ms.SS.'pp'J) '•.�.'':;iU ii`e.°"..J'!irpry(smgte1 ID. I.
• - .
• oIndustriei/Commettiel ' ' .• Residential .
is.GROUT
olrrigatio(r OWells>:100.000 GPI) PROM .- TO fV l7VQfdCTl�efrM uoD BAMovrrr
Non-Water Supply Well: _ •. • •• '_, - , '4 -n •2 3 ize01,f
. bMonitoring . . • : •ORecwery. R . �VILi�*G• ..stD/�
Injection well: JYIz �[
- - OAquifer Recharge' OGrotmdwaterRemediation -_ • - n, , . _ .
OAquiftr 5totage and Recovery• OSelmi Berber _ l9.SAND/GRAVL'LPACR(dappllei6le)
PROM TO MATiItfAL PIVirLACIIN=Nl
OAqurfer•Test OStornlwater Drainage IL lwii ; tlfEiliOD "i
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enmeatel Technology OSubsideace Contra' fb m? "
OEv� •
OGeothetnial(Closed Loop) OTracer.., 20 DRILLING LOG(attoehLddltional sheets if necaa.rr)` ' .
OGeothesmel(Iiealinp�Coohng Retnm) OO her(explain tinder Oil Rerneiks) PROM: TO: ., 'DZS( 11TION(eels,eert.e�,asabe k We.pas dm.sic)
4.Date Well(s)Completed / �. We11 IDd !ti t •
t
to,We cation:
ft: ft.! a .� �.._ f s .i ,
• F.eni1y vnerNnmo . ..: .Fac,7ityID1(if appfiable) is fL SEP-1 6 2024
. gil\; 114,65 t-� 11 1 • " = .%ro h';t 1 ::n : ,�: -7R. it tt hi:i.r..uoa., ... .:ro. .: .1.
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I I I . 2L REMARKS! I I•
C?'6r F. ??::d3 ,
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Cotmty . . '. Parcel identification No.(PIN)
• 5b.Latitude and longitude In de•grees/minntes/seeonds or decimal degrees: ' ' '`
(ifwen field,one l.Nlens it seie1eat). • ,r ,.. • '
J(!7k.•,4W & ' ( 1 5 •'. ,
.N w
, . . . , ,,,„ : 9—i. -
6•Is(are)(he well(s):YPermanent• Or OTemporary •' /'3 So silo eat Well,Cont actor . Date
7.Is this a re/ink to as tadstin cell: `L System& V Iheiily car*'hid the w rt)was(were)consnvaed►naccordomewith
g OYes or �INo• ISA1Vl?r(C 07C:OI00;TVA NOW 07C.0700 WWT Cpnarnrcno r Standards a„d that a copy
• !fthla lra repair,fill our him,hellconwrvetfon fnformrir/on ondeaplahi the nature•ofthe (Phis record/ros beu►prorfdedto the well owner.
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•repatr tinder 121 remark:eatenoron the backofrhfrjorm.
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23.SRO diagram or additional Well details: •8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having siine 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 Oycre in Rdraria Box).You May also attach additional pages ifnec scary
drilled:
•• 3 Za '• " 24.SUB1► v a1�S • •
' 9.Total well depth below land surface: r,
Formultiplenellr11stalldeptha(jd a t(esanQie-3®700'atid7plap� ��). SubmitthisGW1�rit1un30da• 'dais' of well completion per the following:.
10 Static water level below top of casing: , N.b•. ., 24e For Al' wells Origins!:
I/«�mr levelle attars ca,fn5 are +r• ` ([L)•: gel form"to Raleigh,
o£:Wa9r Resources (DWR). .
// i 0 TnfmmeGri>rp �Unr;1G17bISC,ILdeigh,NC27699-1617
11 Borehole diameter 'C0( O on.)" .. •24b:,For Injection Wills Copy to D Underground ,
WR ergrourd Injection Control(lUC)
12.Welt construction metiroil. 4 I Y'
: ,'er'Ogmm;•163G MSC,Relergh,NC 27699-1636
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(4•.turn!ctny Pablo,direct ) ` h
Mk etc . ., . • 24e.For water Sv and O eo Loo Geotbe_ridal Return Wells: .-
county,epvaonmen epartmem o the cotmty Copy.
the
• FOR WATER SUPPLY WELLS ONLY: -
• - 24d.For Writer Welts ,-odtici over 100 000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) j Permit Program,l.11 MS Method of ten[: /�}i r G Itnlergb,NC 27G99-1611
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13b.Disinfection type: ' 1 / l .Amount:. 9 . . .. •