GW1-2021-03056_Well Construction - GW1_20210624

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
i
1.Well Contractor Information:
14.WATER ZONES
FROM TO DESCRIPTION t
Well Ciontruettoor\ainc (� t� ft. ft. O�w
(0 ) 3 fl. ft.
NC Well Contractor Ccnitication\umhcr 15.OUTER CASING(for multi-cased wells OR LI\ER(if a licabte)
'S��C ^ � FROM TO D[A�tETER` THICIu\ES.S MATERIAL
� 1 rt. ft. tin,
Compam Name
s^�/� j,� 16.INNER CASING ORTUT. G. eotherinalclosed-loo
2.Well Construction Permit#: �(J 20.0 g5949 FROM ' TO DIA\t Erg THtCIiN£S MATERIAL
l.xv o/t nplrtierrhlr r,:H,.,re,trvet8>rl j7i'Y7tNJ.,tLtS t%fC^Cie+»»:,.lone.i urn»tcr rh:r tt. ft. a�!S- jin,
!'
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3.Well Use(check Nell use): rt.
Water Supply 1i ell: V.SCREEN
FROM TO. DIAMETER !SI.OTSIZE THICKNESS MATERIAL
Agriculturai E)MunicipalfPublic ft. ft. in. t
Geothermal(hvatutalCoolin_Supply') V'�.dential
dential Water Supply(single) ft. j ft. in•
Industrial/Cot.-..ncn a:: Water Supply(shared) I&GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
on-Water Supply Well:" ft. 0 ft. Dun,.
Monitoring Recovery ft. ft.
Injection Well:
Aquifer Rechu:_ nGroundwater Remediation
19.SANDIGRAVELPACK(ifa Iicahle)
^Aquifer Stor"';and Recover\ rlSalinity Barrier FROM 110 JIATF.RI_ I EMPLACEMEN'TMETHOD
Aquifer Test ®Stormwater Drainage
Experimental OSubsidence Control
Geothermal(C.ac Loop) [3Traccr 20.DRILLING LOG(attach additional sheets ifnecessa ')
FROM TO DESCRIPTION(color•hardness,soilb•ock t .,Grain size,etc.
Geothermal(H_:F;;;:s•Cooling Return) �OtherIexplain under#21 Remarks) !i v rt, Z,/ fu i Ck
4.Date Well(s)(ompleted:, �+�i Well ID# r,.
'5!a,Well Lo�cati-c
t5.e \ Soot f_-In i ft. ft.
Facilny,Owner.\nu'!c-M Cad-- red
ID4(it'applicable)) . fc' i ft.
_(�rYti-- re�d . Fla i!may/W, --f„.. ft.
Plivssieal Address.Ci:\.and Zip
ncan�� 0�/�C 72 1 li o =—� i 21.REit:vRICS
v , t'
County Parcel Identification No.I PIN; n±
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5b.Latitude anu ion,itude in degrees/minutes/seconds or decimal degrees:
(if well field,one k, Iorr_in satficient) 22.Certif-i tion:
,24f> 301 3t,,.9 N5?TOW ig; 130ua3 W 5129
6.Is(are)the Ne:lis) rmanent or Temporary 5i+ .rare„!'C'enified ell Contractor Da
fir sr;;mtm nn,ibrni,1 herehr ccrtt(v than the irvi ts/was tive•rei consin. led in accordance
7.Is this a repay-to:nn existing well: [31•es or jj� tt +rule or l9.4:4't'.I!'ft?i'.[POfr!Pell f'uusuvcanrr.Grin urd.,and that a
lflhIs t,a repant i. a m,p•ua it Ire//rnacarrrnon!»/immune and exrlatn the nature nflhe arl+rut the,rco,rd ha.,been prmvded it,the u•c I/owner.
repair mule-21 rc^,.::r+:,,r,•»on or on tfr;'huek ty thac form.
23.Site diagram or additional well details;
8.For Geoprobe:DPT or Closed-Loop Geothermal Welts having the same You may use the back of this page to provide additional well site details or well
construction.on:' !r'v.-I is needed. Indicate TOTAI.N1 NBER of wells constructn,t:details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUcr10NS
��� ' �
9.Total well depth oetow land surface: JVJ (ft.) 24a. For All Wells: Submit this within 30 days of completion of well
I'irrmnlurlr+rc•1L,n.r^r..drplh,rJdi(/:rain l.:eumplo 34i:2UG'uud?Gr=IUtI^i construction to the Ibllowin+.t:
10.Static water:c-r!below top of�easing: QL./ (ft.} Division of Water Resoui ces.Information Processing Unit,
/(trahr lcrvl,.,an^. ,•,::•, 1617 Mail Set-vice Center.Raleigh,NC 27699-1617
11.Borehole diamet:r:\D t 2 (in.) 24h For iniection Wells: In addition to sending the form to the address in 24a
above. also submit one copy of this farm within 30 days of completion of well
12.Well constri.:tics niethod: _�^
J rnnstruct:.+a a7 the follov:ing: �
(i.e.auter,rotaq.c:.:11c.,iucci push,ctc • ,`
Division of Water Resources,ll.nderrround Injection Control Program,
FOR WATER�:PPL't WELLS ONLY: 1636 Mail Service C,enter.Raleigh,NC 27699-1636
13a.field(-pm) _ Method of test: CoAMC lac. For Water Supply&: Injectioni%yells: In addition to sending the form to
1_ the addrQLs(es) above. also submit one copy of this form Within 30 days of
13b.Disinfection n:r:MtOri f L Amount: k f completion of well construction to the county health department of the county
where constructed.
Form GW.I North Cambria Department of Em ironinernat O uahty-On ision of Water Resn;tccs Revised 2-22-2016