GW1-2022-01192_Well Construction - GW1_20220121

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WELL CONSTRUCTION RECORD(GW--1) For Internal Use Only:
1.Well Contractor Informatioin:
■ � 1 A 9 1' li~A imam
WATER ZONES
r , � A FRpyl TO DESCRIPTION
llcontractorName IL ft
W�� ��U7 � � ft
- �--�-- 15.OUTER CASING(for mulfi-cased wells OR LINER.if a licable
NC Well Contractor CearifieattonP+umber
FROM TO DIAMETER TgICIt`iIESS MA'I'�Etrtr(AL_
a t r f ft B ft ''lic, D. T, "v
Company Name �." 16.`i INNER C G0RTUBINGt eothermai LESS MATERIAL
% FROM TO DL1tlEfER
2.Well Construction Permit;#: 1 ft. f{ in.
List all applicable we11 constriction permits(i.e-UIC,County,State,Variance,etc) ft. ft in.
3.Well Use(check well use): 17.SCREEN arnTERIAr
Water Supply Well: FROM To ft DIAMETER SLOTSIZE TincKNEss
Agricultural lYIunicigaUPublic
ft in.
Residential Water Supply(single) fL ft rn'
IodustriallCotn
Geothermal(Heating/Cooling�Supply)
mercial Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL FAULACEIVENTbiETgHOD&A�fOtfiT
Irri ation /� ft. I R , ;J
Non-Water Supply Well: Ls ft. it.
Monitoring Recovery
Injection Well: ft ft
Aquifer Recharge rp�l^�Groundwater Remediation EurnLACEnIE�rryglnov
l.�t 14.SAIrtD/GRAVEL PACK tf a livable
�ySalim Barrier FROM TO MATERIAL
Aquifer Storage and Recovery � ty � t1,
Aquifer Test oStormwater Drainage
Experimental Technology [)Subsidence Control
ft ft
Tracer 20.DRII.LING LOG attach addifional sheets if n
Geothermal(Closed Loop) FROM Tp DESCttIPTtON{eofor,hardness wiUrocl a size eta)
Geothermal(Heating(Cooling Return) Other{explain under i121 Remarks) ft. t ft-
Wel1IDr '.
4.Date Well(s)Com�plAeteEd:� `/�� 4� ,i ft. ,. �ft
Sa.Well Lecaiion: lwtl<�t t �``U JC'� ` ft
ft
1t. ft
Facility/Owner War., Facility lDfF(if applicable)
ft ft
., e ,
OV ft ft.
Physical Address,City,and Zip 21.REMARKS
County ! ParceI IdentificatiouNo.tPlq
5b.Latitude and longitude in degreeskmmut--seconds or decimal degrees: 22.Certification:
(ifwell field,one latilong is sufficient)
Si
of Certified Well Contractor
Date
6.Is(are)the wells) Permanent or oTemporarg
Byg this form,I herehy certify that the wells)was(were)constructed in accordance
02C.0100 or15ANCACO2C.0200NellConstruction Standardsand that a
7.Isthis a repair to an existingwell: []Yes or No his record has been provided to the well owner.
If thsisarepar,filloutknownwel{construction information nd explaln the natrtre of SheSite diagram or additional well details:
repair under 021 remarks section or on the back of thisform.
You may use the back of this page to provide additional well site details or well
8.For Geoprobetl)PT or Closed-Loop:Geothermal Wells having the same construction details.You may also attach additional pages if necessary.
construction,only i GW-1 is needed. Indicate TOTAL NUMBER Of wells SUBMITTAL INSTRUCTIONS
drilled:
face- 00 24a. For All Wells: Submit this form within 30 days of completion of well
9.Total well depth below land sur
For multiple wells list all depths if different(eramp e-33@2'0'and 2 a@1001 consruc ttion to the following:
rces
ift.Static water level below top of casing: I t
e (ft) Division of Water Resou ,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
If water level is above casing,use"+"
Il.Borehole diameter: C� (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:
construction to the following.
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276991636
r13a.
WATER SUPPLY WELLS ONLY: r form to
Method of test 1�� 24c For Water Snauly&Iniectioa Wells: In
hiis form sending
30e days of
Yield(gpm) ' __ the addresses) above, also submtt one cony went Of the county
Amouat completion of well construction tOthe county health dep.Disinfection type:l where constructed