GW1-2022-01844_Well Construction - GW1_20220216

WELL CONSTRUCTION RECORD 7i�_
This form can be used for sinete or multiple welts
1.Well Contractor� Information:f I S I ' ��� r W'�Tt. T To S
I L PTto
1 M O DBSCRI
Well('ontr•actor\au:c
f
nib
6- i
FEB 16 2n�2 ft. ft. i
NU Well Contractor Certification Number �e (, Uni 1 O—.*4 ERC,tStNG formitGi-essed1 0 ORLIrFE. "a
,( I t='f^. e-.kR l FItO�t TO DlAatt:rm rgrCKNESS MATERIAL )'
ZF WtlI brl (Ii1'9Glln'o-r+aR• O --
� u; cx� rt. fr. a( v
Compam Naina ■M�h 16.INNER GSXKG OR tier-' 'el .don
N I 1(,J��O FROM T0. DIAMETER TAtCK.�'F5S MATERIAL �
2.Well Construction Permit M ft. ft.
i v ag appkwh/e xrJl er,uatrurrian permits(i.e.f•aun¢•,Stare.Parmelee.etc./ fa
3.Well Use(check well toe): 17.SCREEN
\Pater Supply Well: FROM TO I DIAMETER I-SWTSIZE T1 31-0ESS 1 MATERIAL
ft. fe. in.
=Agricultural cmunicip0public
=Geothermal(FeatingtCooling Supply) Qftesidernfal Water Supply(single)
Et. Ct. in.
14
�tndustnaiiCammercizi f7Residenna}Wafer Supply(shared) M GROIFT
I FROM TO %IXTFRIAL Edtet ACEML.'r SCROD 6 AMOt'WT
=irrigation, ft. a�'& fY11X Y
Nou-%Vater Supply Well: tt. ft.
0\40nitoring GRecovery ft. ft. 1
1 Injection Well:
uAquifer Recharge OGroundwater Remediation 19..SANDJGRAVEL.PACK . e
FROM TO MATERAL atfrNOD
I CAquifer Storage and Recovery OSaliniry Barrier
❑Aquifer Test Mtonnwater Drainase
ft. ft.
CExM.knental Technology =Subsidence Control 20.DRILLING LOG attach additional sheets if a«zssry
::Geothermal(Closed Loop) OTraeer Fan. TO DESCRIP P70\ tafen hatdrfM so&rock e.•n)n sire.erc.t
1 CGcoLhcrmal(Seattn Cocll n Return) =Other(explain under 421 Remarks) !a ft.
-�, �oaa ft. ft.
4.Date Well(s)Completed; � ff. ft.
;.11'61 Location:
Vodep. ft.
t artl4y Ouli:Mnit ha; lip 1D-(tfapplieable) {t. ft.
1406 MP-0 ROlm (1. fL
Physical Address.Co>,and Zi 21.REMARKS
_6 o31
C'uut:u. Pareelidetuilicwiatlt0 (PIN)
.rb.Latitude and Longitude is degrees/minutes/secouds or decimal degrees: 22.Certification:
(tfaell field,vile 1,10ong is suf6otetx) /
`� Signature of Certified%Veil Contractor Date
15lC
6.is(are)the well(s): ermanent or OTemporary gy.rJrnofg this fnnn.I herrhy corny thul the srelffi)uaf At'eni rrutwrat rd ill trcrrelknigc
a•ldi JSA Ni'A('Wr'.Ol0u nr 15.4 YI'AC 02%, 0217+1)4'eil C}mHrt clrcm.6nurlanl:curd 1hul tr..
i.Is this a repair to an ettistitig Well: Oyes or 1) VO trips ul thu ree»rd hox hero provided to the wel/tin'oer.
11 riei..e.,o reparr.rdl oat krnmW yeU unastraeiirnt Mforinolion and aaplain dre nnlrrre at the
re/wrr under..2J rrawrkr sectinn or at the hank of this fnnn. 23.Site diagram or additional weil details:
I You may use the back of this page to provide additional well site details or tn•all
R.\umber of wells constructed: construction details You may also attach additional pages ifneeessary
Feu nurhipJe n7JecYeua ur itan•n'o/c r.rnppA•a 1ilr ONLY H'llh/he some ealtttrmertan.fall ralt r`1•
24.5ubmittal Instructions:
,shout r,ne lnrwr
j�C/
9.Total well depth below land surface: V J (ft.) 24a• For All Wells- Submit this form within 30 days of completwn of%%ell
For nnrhiph it ells 11s10 depth..it dilierral(extmiple-3@2($Y oiul2 R Jim') Construction to the following
Division f terqua
617 3• Slit iafor_mation Processing Unit,
id.Static-aster level below top of casing: �� (ft.) Center,
- —
!1 unite l;a•I i.r,Jtrn•r.a..nr}.n..o.. !f,Raleigh,\t:27699.1617
1
1.Borehole diameter: (in.) 24b. For 1 iection W ils: In addition to sending the form to the address in 24a
t
}� above, also submit a copy of this form within 30 days of complcuoi: of:veld
12.Well construction method:_ construction to[lit following.
it a au-ger.roiwy.csb:e.dust push,etc.) Division of Water Quality.Underground Injection Control Program,
i3.FOR RATER SVPPI-Y WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276".1636
13a.1'ieid i•4ethod of test:
I t 24c.Fee Waxer Sannly&t,cafbertaal V1rells: In addition to sending the form to
(e'Pm) t the address(es) above, also submit one copy of this form Within0 ays o
13b.Disinfection type: Ch�Q>!in�_ Amount _ completion of W y
eil construction to the county health department of the count
where constructed.
Form GW-t Korth Carotins Department of Environment and ratans)Resow4lis-Oil-tsion orwaser Quality Ile.tsed Jar.2011