GW1-2021-03554_Well Construction - GW1_20210823

1
WELL CONSTRUCTION RECORD"(GW-I) For Internal Use Only: k
I.`V 11 Contractor I Zma"
on: {
O J I L IVA. ZONES #: ,
Well ContrncterName FROM To I DFSCttR'TroN
ft. IL j
n eirA 4
NC llreltCoatrnctorCertification Number is.OLrrER CASING for,maid.ec a i+veila)ORLINER a Me
FROM I TD DIAiNt:fER:. TMCKNM NtATERIAL
W� ft.
Compan}Name
16.AINER CASING OR G-faeolkeriuldoted4papi
2.Well Construction Permit#: Ft2Oat TO DrA DETER TBICKNIM I MATERIAL
Do all applicable hell ormvnx1hur pemlits(i.e.l t1C,Coruikc:Stare.t'arioncr,etc.; )r�r5 IL ', tt. in. CC (WO
IO
3.Well Use(check well:use): ft ft. in. T V
"Vnter Sapph•Well: 1 7.SCREEN o I DL►s1MR St tYrsw THIMESS 5IATERIAL
Agriculttttal OMunicipuUPublic 0 f. fd.
Geothermal(HeatinglCooting Supply) of�esidcntial Water Supply(single) ,70,�_.. 1 �ft'
IndustriallCommercial ResidentialRraterSupply(shared) S v
lrri lion FROM, TO AtA ES1tPL1CL,NMNT►ILTHOD&AhtOl.;\"r
Non-Water Supply Well:
Monitoring Recover}+ ft. iL
Injection ell:
-Aquifer Recharge DGroundmater Remediation
19.S.AND/GRAVELPACK(if a leabie
Aquifer.Storage and Recovery Dsalinimilarrier FRmt, To MA i t tt23 air rHon
Aquifer Test DStormwater Drainage tt• O!t• S I-
Experimental Technology DSubsidence Convoy
RGeothermal(Closed loop) [)Tracer 20.DRILLING LOG fattsch additional ibeets ifaeema
Geothermal(Hearin Goblin Rewm) n0ther(explainunder#21 Remarks) FROM TO .. DEst wrrtox eobr hardruu.iowrad: mo strzera
R. . Rc
4.Date Well(s)Completed: ,� . Well!D# ft. f-
Sa.Well Locations s�f• I iry
iL )rb1
t►��,owl �R(L� n. f..
FacilitylownerName Facility(D�(if applicable) - R• >
P(n'sical s,City. d zip fL
CLP'1r• --t 3-Z 21.REiNAM
• r
my �V
Cou Parcel demifrcaiiou No.(PIN) � � t-A ':On
5b,Latitude andlongitude in degmWmitiiiiWseconds ordecimal degrees:
OrIN 11 field.one hu/lorrg is sufficient) 22. rtilieation•
6.Is(are)the wells) ermauent or OTemporary Signature fiedvWell Conuactor Date
lh sigrrirrg thk fnrnr,!lrenehr C•rrl rhdi fire uril/al i+av hrem):carrsrr;&ed is ik-cy !rant
7.is this a repair to an existing well: QYes Or 5�Kl o tridr lSA AV AC o2('`.UIOD ar 13A MAC 03t'.0200 II di Crmvrudraa goidants mid tint a
j(dit Is a nVari fill ox himm well rnnstrwitm fii'fiNtoarhoi mrd o pWa the miture ofihe oV.v df lhis recoal hia hwt prmvded up OL
no inner.
repair miler=21 nmrbrlpsetwon ra•an the back ofib0forra:
23.Site diagram or additional Deli details:
8.For Geoprobe/DPT or posed-Loop Geotherinat Wells having the same 1'ou may use back of ihs pa_ee-to;provide additional-well site details of ivell
construction.only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details.You may alsoagach additional pages iftiecessary,
drilled: 1 SUBMITTAL 1NSTRUCTIONNS
9.Total,well depth below land surface: � - iR•Y"•2,m,-For All Wells: Submit this form yt mthin 30 days`of completion of well
F ornmltlple wells list all depths irthfferemt(—pie-3 rr 200'cord2@1001 tp on to the foBowing:
10.Static water level below top of casing: (ft) Division ofWater'Resources,lnfon nation Processing Cinit
Ijunrrr lerl u abur�nary»g fise - 1617 hfuil Service Center,Raleigh,Nt:ZT699-16i7
11.Borehole diameter: r (in.) 24b.For tnicedioii bells: In addition 10 sending.the form to the address-in 24a
above,also submit one copy of this fdrm mithin 30 days of completion of well
12.Well construction methode o �� Y p
(i.e.auger,roman••cable-ditto push,etc.) ., construction to the fol)otviiig 6
Divlsion of i636 Witter
Resources,Bernet Gen round injection Control.Program.
FOR WATER SUPPLY WELLS ONLY• 1
• ter,Raleigh.it`C 29699-1636
13a.Yield(gpm) 5—D McNtod of test: L AA_ 24e.•For\'4atEr Suonty&.Iaie¢dioa\VeUs:f]n addition to sending the form to
the•address(es) above, also submit lloiie copy of this,fbmt within 30 days of
13b.Disinfection type: \ amount. 1.C completion of Nall construction to the county ha tth department of the cotlfity
where consweted
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