GW1--06181_Well Construction - GW1_20241021

•
WELL;COIVSTRUGTION RECO (G'W-.11, • For Interpol Use only:
1.Well Con ,r.Iaformation:
•
,
:14 WATER ZONES I 'I'
,: c ., t„/I•, l•is ; -Thom To s 1 DUQmioN. .!�'; ' : •
%f!p ft.• 6/? [al
NC Well Contractor a'�r�a :a . �-- it ..
Codification ? t:ri-Q-.r'll: 'i'El1.
-.IS.OUTER CASING(for nsdq-Crud wells OR
•
3 rU=lJh �9`v.• °y', ''r' �M D1i1MErIR LINER Ofaa liable)
Compa�rNamo /F��Kn ( 'l .. R ;R I
MATERIAL
2.Well Constnetloa Permit S: ` ` i 1.A ei`, 2D 2? FROM n CASING ORTUBING(eeotheraJ etard-lop) •
List all oabla wall DLialIl7rlL' [�QOI s MA1ZRIAI,
egyll eenrhuiellon Fermate n e.UIL,County,State,vartaaee,ale) fl �-j
•
3.Well Use(check well uue): `tI ` l5�� ��r( t. eD `!_
Water Supply Well: - .S J7.SCREEN .
OAgricultural •• l]Muaicipal/Publie PROMlt TO .1 D-Anurrsai SLOT8IZR TinCIWLSS MATARLU.
OGeothermal(Heating/Cooling Supply) idential Water Supply(single) ! '
OlDdustrioYCommercial !fj n I'
Rpiduitid'Water Supply( • IL GROUT
• Olrrigatiop OWells>100,000.GPD 'PROM TO MA tr
niwiaCiasi•na sona�Aniourii•
Non-Water Supply Well: :,� r „ eat M'
•
Injection Well: ORecwery._._ !t ft.
( I YY/ .
-. • • OAquiferRecharge •°GroundwaterRemediation lc
a
OAquifer Storage and Recover3' OSdmityB turier II.SAND/GRAVELPACB:(flppueable) • ' .
PROM TO 1. MA7sRIALLACt3lztfrMlrgOD•
OAgirifer Test, OStoimwaterDnimge R R
OExpuimmll Technology"
OSubsideoce Coiitra ft•. R
' ' OGeothermal(Closed Loop) • OTracer '20.DRILLING LOG(attach additinual rheas if Deanery) . '
OGeothermal(Heating/Cooling Rom) , OOther PROM • TO Dssc�n4N(r.ur,rmt.ea,..ttb ies,K,Q,j,dn. )
(exphtin under uY21 Remailm)
4.Date Well(s)Completed: /0 -2-i
Well DN/ 1
5a.Well Location: n m
1G' D�Q 1^S . n +
Faality/OwnerN T - ,
• Paa7ityIDt<(if aOPliable) R R .a k ; '
' • v • [o 22 Li 1• MI t. CAN RaA �/ ":.,• •, ill.' `�
AJ&C••.taty and rara�-- G" f o r i 9 1 2024
J r l�_ 21.ItZMARE3J • '.
•
PoealIdmfifiralioallo.(PIN) !!; G vk: .
County
•
56.Latitude and longitude In degrees/minutes/seconds or decimal degree :
(if well field,one lat long is aufficieut) •
22.Cert'tfi
N i
W . ..,
6.Is(are)the well(s): Permanent or OTemporary 1�+ sisa•�se of atrectc /� Z
l—/Q Date
-_By stkalnsiNtform.Ihersbyeerl/jy that rhewell(r)wns(twig 1eanrtractedlna nianecirllli:
'7.Is this a repair to an existing well: Oyes or No• :-'' -ISA hr.,/C 02C:oloo or'7S414C4C 01C.0200 Well Conitnrtlon Standen*and ilia a copy
If thl:is a repair,fl1 via Maim well a augwdon al(aamllon
' 'repair ender VI remark section or an the backofth/sfores �°�the nolm.ofl ojrhrs meant ha:been'welded to the wellalma
. ` 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closer-Loop Geothermal Wells having the sane You may use•the back Of this'pago to provide additional well construction irk'
construction,only 1 GW i.is needed Indicate TOTAL NUMBER of wells (add'See Over'w dmarla Box).You may also attach additional pages if Daesmiy
drilled:
24.SUBMITTAL INSTRUCTIONS '
•
9.Total well depth below land surface: ' ' C/O •
ForandBpla wells it,all depth((Venn,( 3(aj700'and 1�00) It)_ Submit nibs OW-1 irithinl30 days of well con pletian per the following:
' , 10..Static water level below top of casing:
Ijsiisrafcve/kdbaysaardryiae+ (n) 24i. For All Wells: Original form to Division of Water Raso
/ Information Processing Unit,1617 hLSC,Raleigh,NC 27699-1617 u•cea
11.Borehole.diameter. 6!k ) 24b.For Infection Wells Copy to DWR, •
1 Underground injection Coahol(N�'
12.Well eowtcaetloa method:
tS 1 aYt1 ._ Program,3G36 MSC,Raleigh,NC 27699-1636
IL ruder, oni wbla,dart 1.Y' - , _ •
pub,etc.)
24e.For Water Sopplyand Opep-Loop Geotheriaa(Retva Wells:Copy to(he
. county eaviranmpal health department of We county where installed FOR WATER SUPPLY WELLS ONLY: ' •
•
24d,For Water WeW prodder over 100.000 GPD:Copy to—DV/It,CCPCUA
• Ile:Yield(gpm) ` a U - • . • Method of tab -4 i r • p°"° .1611 MSC,Ralergh,NC 27699-1611"
�. 1 .. • • • • •• ti
13b.D1siafeetion type: 1'f f H Amount: 12-•P?/ _ I, ,