GW1-2022-00940_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1.Well Cuntractor Information: 1n
Q�F tQ 14.WAF£RZO-
Oh{f i,s��,Y FROM TO DFSCRIPTIO\ �
Well Contractor Names ft.
NC'Well Contractor Certification Number IS.OUTER CASING for mnfti-cued wells OR LINER tfa k) <
FROM TO DIAMETER ,r THICK.NESS MATERIAL l
oft. ft. , i }s as v
('ompam Name 16.INNER CASIN OR T{TBih theriml closed-ioo
r C, 1 ' 0��0 FROM fL DIAMETER THfCKtiFSS MATERIAL l
2.Well Construction Permit#: J W ft. rn'
0,i all appkwhle ited crrns+ractiun permits h.e.Casino-,State.I arinnc..elc./ ft.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO I DIAMETER SLO SSIZE THiCKNESS I MATFRlAL
ft. ft.
3- Agricultural OMunicipal/Public
DGeotherinal(Heating/Cooling Supply) Q(Residemial Water Supply(single)
73lndustrialiCommercizi ❑Residential Water Supply(shared) GROUT
FROM I t0 :NATER1Ai. i E.atPLat:1'ME\TMErli0D6A.%t0t:\7
`Cirrigation fa. a� `ft. >NIIX Y
Nou-\\'titer Supply\Well:
❑'Monitoring GRecovery
I injection Well; ft, ft. I
OAquifer Recharge --Groundwater Rcmediation )9..SAND/GRAVEL PACK ifs licable
OAgtuter Storage and ReeovM' DSaliniry Barrier FROM ft TO if MATERIAL E>tY1ACEMe.w.mi ritOD
GAquifar test OStonmvater Drainage {r fr
GExperiniental Technology -Subsidence Control 20.DRILLING LOG anaeh additional sheets if neegasarif
�Gcothermal(Closed Loop) DTraeer Paoli TO DESCRIP110N teotor,hardness.soiYrock fv e,•n;n sire.tic.
CGcothcrmal(Heating/Cooling Retum) G'Other(explain under 421 Remarks) 1 it ft.
(n,-, Q fr. ft.
4,Date Welt(s)Completed: 000 � I. �I ft. ft•
i.Well Location: 1 fr.
I�irxlh rm� kr-&n
F;;cd4\.0%uter Nime l actliq iD-Ufapplieable) 02?
31 1 [ox K.V. ft. fc
�t
pit sicai address.Cris 10 d Z. 21.RENT\RKS
1sa &, 3
Comm. Parcel tdetuitieationNo (PIN)
Sb.Latitude and Longitude in degrees/minutes/secouds or decimal degrees: 22.Certification:
pf well field,one lot long is suf&ienq
Sianature ofCcrtifaed Well Coninclor Date
6.is(are)the well(s): 14rmaaent or OTemporary Ky.<lu+nag ihis Jr+nn•l hrrnhi-tern(,thut the well(.,/lied fl+•eny t•nctrtrooell n+crcc'nr:(uncr
1 withiSANCAUON..fl0UnriS.Atic-At•ei-%• ft2lJuJireil(bnarrcimnSiandar(A and lbut
7.is ibis a repair to an existing well: Dyes or StiN'o g ffits rem?d has hero pinvidrd ra the well ux•ner•.
//tin.,to a repair:fill nut katnvn».ell cruutrurmur to/nrmonan and vrplurn rile nrn+,rc r!1 the
repair under..21 roatarkr.rrc ion or nri the hark yftbis fnnhi. 23.Site diagram or additional well details:
1 You may use the back of this page to provide additional well$ite detail,or%%•ell`
8.Number of wells constructed: construction details You may also attach additional pages ifnecessam AS
hi,r nndtrple imm um,or non-u'n/c•r.rnpplt•a ells OA/.F'u'nh Ihr.came rruxripardan..iml cat; c
uhn+unnr/nn,r 24.Submittal Instructions:
9.Total well depth belo v land surface: 3 `(J,�JC� (ft.) 24a• For All Wells: Submit this firm within 3U days of completion of%tell
Forrnalflde i,e1A hit all depth.,+l ch/lereat(e.romple-1w2MYond it/riff) Construction to the following
Q /
10.Static water level below top of casing: (�D (ft.) Division of Water ce Cent,r,Raleigh,
Processing Unit,
n,iar.-r l,•,el r.uhr+rr cu..m}.rr.,.•" 1617�•Iei{Servile Center,Raleigh,\C 27699-1617
21.Borehole diameter: (in.)
24b. For iniection Wells: In addition to sending the form to the address in 2.1a
W
glove, also submit a copy of thus form uwithin34 days of cutnpleuoi: of'Weil
12.Well construction method: L�n�Jae ti construction to the following.
lie au-ger,roiAry.cable,dare,:t push,etc.) ram
Division of Water Quality, ,
Underground(nicetion Control ro.
13.FOR WATER S[tPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I / 24c.For Water Suonly&Geothermal Wells: In addition to sending the form to
13a.field(gpm) Method of test: the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
13b.Disinfection type: �� Y iYl{�_ Amount:_• where constructed.
Fora,GW-i Noah Caralina Depanment of Environment and Nature)Resources-Division of Water Quality ire,,scd Jan 2011