GW1--05761_Well Construction - GW1_20240926

I Print Form
N•F'Ll.CO`S RI'l l'll!N 1tF(:O1t1)tC -1)
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w r;__-ny,e \,.n. S3a fl. 3.f h /p
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\, w t,r. n, ., •..e i; , „s.,et,tr. IS.OOtER t ASING(E r model tredv e*t, .,Pk;tdeL
NW Poole Weil and Pump Company Mat tO OIA.Martn rtla[atatlt7l MAtTRIat 4
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/7 IL i C in. f . (ft-
.n,tan,�,nr 7 Ia.INNER CASING OR'I(MING(lenthermil anted-Inv)
AA ell t-nnntrnrlinn Permit d: l I FROM IO IDIAMEtER 1RIr.term DNA renal. 1
) ft h• In.
. -'•,1rAl,'wv..„„, ,tenon rerwnit('a 11A'.r-nlrrrn'.yyn' l'onrn,ie,Cs- _
ft ft in.
3.well i'sr,check well use): -
17.SCREEN
g titer Nappl•AYe11: FAoltl TO DIAMETER SLOT SUE imRRRN[AS MA rERt41.
\rncultunl aktunicipal!l\1111ic ft. ft. In.
i,ertheimnl(llcoting Crvlmg Supply) alRcs,Jtmhal Wale!Supply(single) D, R In.
t:3In.2uvtnrI'i rrmmcrciol 0Residcntial Water Supply(shared) -I>G GROUT
— --- -
•ImcalIOn FROM TO MATERIAL '-E.MPI. FNsxrsF:rIA,a asunn
(� rc .2 o f t `'Iorip i. ff�.k 2
Non-Water Supply Ne11: tlQr Eli
II
Monitoring a Recovery ft. ft
Injection Well: ft ft.
0.Ayciter Recharge QGroundvsater Remaliouun
19.SAND/GRAVEL PACK if appllntde) �_�
°Aquifer Storage and.Recosers Salinity Ramer FROM To MATERIAL — I-EMPLACEMENTSIETRon
0AquiterTeen 0Stormwater Drainage ft. ft.
£E\pcnmental Technology 0Subsidcncc Control ft. ft
niseothermai(Closed loop) DTracer 20.DRILLING LOG(attach rddidanal sheets if neces,en)
FROM TO D SCR IPftON(sear,h.tdent,+a.Ur.*type.Brun+we-.s/
a geothermal Hewn 'Crustal'Return `Other(ex.lain under ti21 Remarks) 0 •
ft. a ft. �P '�d j L
of t
4.Date Well(s)Compkted: 4-2?-Ze-f Well Ma d ft ToZ rt. ir.
Ss.Well location: 11 ft 265
ft �W't'
wii11�1/,�34r� ft _ .
FoettrtyOwner Name Facility MO(if applicable) ft ft
S I .0er5 j'2, 2eb1.)on Nc 2?597 _ ft ft
Physical Address.City.and Zip ft. ft
MARKS
I.
f krill-1,n 21.RE Hardened drive shoe. T - 7:..9 Uptit
Counq Puccl Identification Na(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one let/Ions is,cIF.ocnt) 22.Certifie
35. )zR i.a N — 1 a. 32cocxxc * 17-xf
6.Is(are)the wcll(s))Permanent or Temporary Sian of Ccrvficd Well Contractor Dar.
By signing tins form.I hereby certify that the walla)was(weed cvnrinicied:a acx.'la„c
7.Is this a repair to an existing well: OYea or �%No with I SA N/'AC Inc 0100 or/SA 1CAC 02C'.0200 Well Construction Siunntnl.and:;en.
!Iilu is a repair,fill out brown well construction information and explain the nature of the copy of this record has been Provided to he we!!owner
repair under'?/remarks str:ran or an the bock of this 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\sell site deraais or sirel.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary
drilled 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: IQS (ft) 24a. For All Wells: Submit this form within 30 day,of:om(uatkon of•.e
I'or multiple wells fur all depths tf different(example-3@ 011'and 2r@l011') construction to the following'
10.Static water level below top of casing:_ ZIJ (ft.) Division of Water Resources,Information Pracnsint Unit.
If eater keel is abase cost g,arc"• 1617 Mail Service Center,Raleigh,Nt'27.6.N-161'
II.Borehole diameter:6 (in,) 24b.For Iniectioo Welk: In addition to sending the form to the a.:d:e..
�-/r above,also submit one copy of this form rthns 3.)days of compicesi
12.Well construction method: l�U�r (/y w
construction to the following:
i C.auger.rotary,eater.direct punk etc.)
Division of Water Resources,L''adergrouod I ajectieeCedrave Pni-r,.a.
tOld WA'1l R SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC Y7104-Ie3o
I3a.Yield(gprn) Method of test:Blow 24e.For Water Sappl9&Inieetiun%S e1ikE iaailtlrllai 010 aeeir Sfa
dlhe ea•►.
amply la the address(es) above, also submit ono amply lie foes wake 30 de et
131,.Disinfection type:NTH Amount 1 Ib• completion of well construction to the coulter i1Jb epehRRat at die away
where constructed
I um Ir W-: Nwtb Carolina Ilepanmcra of Ern truuurcntal Qwalip-Otesa.on at W,cc,Rd..e..r. T..,:K3 2"22-