GW1-2021-01106_Well Construction - GW1_20210322

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
FROM I to I DESCRH'DON
Well Contractor Name
n. n.
NCItJ C 4303 rt. h.
NC Well Contractor Cenification Number 15.OUTER CASING(for multiantud wells)OR LINER fd a ble)
``'' FROM TO rd M=R THICKNESS NIAT`E/RLIL
lam\ Is O n. t n. ^� in.
Company Name 1//''�V(j,,,,� ``1 16.INNER CASING OR 70BING 1 thermal dosed-1 )
2.Well Construction Permit#:b 1 Ub(I FRONI TO DLIMEIEA THICKNESS NIATKRIAL
fJn all applirnble well oonsvneriun prmnirs fi.e.UIC.C-noM Score.Valiance err.)
3.Well Use(check well use):
Water Su 1 Well: 17"SCREEN
rPY FROM TO DUN!gjER SLOTSIZE rinl NESS MATERLNL
Aericulturel y©MunicipaVPublic n. f1. is
Geothermal(Heating/Cooling Supply) ,►�Iµesidential Water Supply(single) n. n. in.
IndustriaVCommercial C❑DResidential Water Supply(shared) F&GROUT
brivation FROM TO MATERIAL ENIPLACENME NFE-t'ROD&ANKHJNT
Non-Water Supply Well n' l n" I)r I
Monitoring DRecovery
[gjectian Well:
n. ft.Aquifer Recharge ❑Groundwater Remediatinn
19.SAND/GRAVEL PACK(if a icable)
Aquifer Storage and Recovery ©Salinity Barrier FROM T
NUIERIAI EhIPLACENIENT METHOD
Aquifer Test ©Stormwater Drainage R n.
Experimenml Technology QSubsidencecontrol
Geothermal(Closed Loop) QTracer 20.DRILLING LOG fathch additional sheets if )
Ff
TO DFSC 0,%oolor,h+rdMs.saiVtnekn a,Nc)
Geothermal(Heating/Cooling Return) Other(explain under#21 11Remarks)4.Date Well(s)Completed: o�'o� Well 1D#d)6Uo�l �5W B Location:CP fL
Facilin,.DwnerName Facility 1DN(if applicable)`� � iEM�5 -R 1 O�ZcY1 C.0 n.
Physical Address.City.and Zip
MA u N n LD 21.REMARKS
County Parcel Identification Nn.(PIN) p n _
5b.Latitude and longitude in degrees/mioutes/mconds or decimal degrees:
(if well field.one Inviting is sufficient) 22,Certification:
N W DDMI- -��-a�
6.Want the welllsl emoment or QTempom" Si_e more of CemfeJ Well Contmcmr Date
R, �iening this torn.1 h,,eb ,erdfr char dre uel1(s)nun Itreret mnnruned in a,n>nlan,r
7.Is this a repair to an existing well: ©Yes or I�IIO r 15A NCAC 02C o
xi l00 or 15A NCAC 02C.0200 Nell Convnatimr Standards and dean a
//this is a"Inn,fill....f t to,,cell,onsrmrlion infonnariov<n.d eerplain die nani,to the ''olo/This record has been pmeided m do aWt corner.
repair under=21 rernnrk.,seerinn or,n the ba k of this joint.
23.Site diagram or additional well details:
E.For GeoprobefDPf or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
constructuln.only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: —10 (ft.) 24a_ For All Wells: Submit this form within 30 days of completion of well
For mulurlenWis list all depths ifrl erenr(e¢mrple-3@r200'und2(ulo0') construction to the following:
1 1
10.Static water level below top of tRsiug:,"�1[/J (D.) Division of Water Resources,Information Processing Unit,
If tearer/ere/is abnre,,sing.use"+" 1617 Mail Service Center,Raleigh,NC 276"-1617
11.Borehole diameter: (in.) ( 24b.For Infection Wells: In addition to sending the form to the address in 24a
1 n I Cy I O �, \ above. also submit one copy of this form within 30 days of completion of well
12.Well construction method: Ilt K 1` TLI lJ construction to the following:
(i.e.auger.unary.cable.direct push.etc)—r
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ,n p 1636 Mail Service Center,Raleigh,NC 276"-1636
13a.Yield(gpm)1 Method of test: 4'T 1 1` 24c.For Water Supply &Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of [his form within 30 days of
13b.Disinfection type: QL Amount:C3� completion of well construction to the county health department of the county
where constructed.
Fours GW-1 North Catalina Department of Environtmntal Quality-Division of Water Resource, Re,ised'_-22 2016