HomeMy WebLinkAboutGW1-2022-07663_Well Construction - GW1_20220818 Print Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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FROM 'rU UF.S(RIPTH')N
t
tt'ell(.innracan'Name '7[�fl. SF fl. `4 i G f
3 b'7G AMR
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N(,'Wetl l'ontrucu,r Certification Number 15.OUTER CASING(fnrmalti-eased wells OR LINER if a IicaMe
FROM lU ULY\11•a'F:Hj "r111fKNF:SS Nf:\TF.Rh\I..
in.
J
fl/nglaay Hann _ 16.INNER CASING;OR TURIN(: rvothermal c osed.I
FROM TODL\AtEI'FH TRICKNF:SS \I,\TF:HLU.
2.Well Construction I ermit N: �Q / �/ � h ff• in.
tisr all appllonhle well runatr•ur•nmr per•mitr r1r. UH•.('nurnr,.1'hrte.F rivaee, ,It J
ft. fL 'in.
3.Well Use(check well use):
17.SCREEN
Witter Supply Well: PROA1 1'O 7)L\11FTF"H SLUT 517E TIIICKNF"SS AL\TI:HI U.
unicipal/Public n, in.
Acriculuurd Li ft.
Gcuthennal(IlcatingiCooling SupPlyl Residential Water Supply(single) ft. ft. in,
Indusvial/Commercial OR c I "U �) h' d IN.GROUT 'fU.
F'HtiAt VIAMRL\I. F;A1PL.\CEMEYI AIE nd�111O AMUI'N'1'
Irri'anon ft. ft.
Non-Water Supply Wdl: --
Ra•ot
t 4onitoring } (+
Injection Well: ft. ft.
'Aqui(er Recharge [�( .{ajq� .j tl��Fxcti w��Urlp _ 19.SA '1)/GRAVFI,PACK(ifs Ilcuble
Aquifer Storage and Recovery Salinity 13@t)jviQ1B0C F'Ro\t TO Atnl'F.ItL\t. F:AtI'L:\CFAI F.S'1'A1i.THt)D
Aqu i for Test DStonnwater Drainage ft. ft.
Stibsidence Control n, ft. ?
Esperimemnl Technology I
Cieulhcnnal(Closed Loup) QTracer 20.DRILLING LOG attach additional sheets if necessary
ll
FROM TO DESCHIPI'ION(ewnr,hardn"%.,"iFrftck Iv Pe. rain aite,"0
Cicothermal(I lealine/Coolin r Return( Other(explain under 421 Rcntark(s) 0 ft. /C ft.
4.Dote Well(s)(:nmpleted: 7 Z Z hell ID# ��7 V—3 "/ H. S ft. 6-A/
3 ft. ble 4 e : / c.s,v r._ r e r
$a.N'elld.ocatinn: —�
_ ,S ft• S�� It. ' �Jars.:� f'ct f!-•
..� a�mEr a kt Ne�Y���'
�" rt. rt. j
Facdll�''t)ene.Vann Facility Ibu of aphlicnhle) I
A.
ft. . I
Ph)eiail Addle—City.and ZIP
/1 /t 21.REMARKS --
I lztlr✓�dL 1 Olt/ LUC/( (. csrN�m.yc��Q Lam'�/l/1�G.� C"(n r.
ounri
Fmccl I dcroilic;w(Ill No.il'INi ' e �• ,r
'F�@e's"..�\ �,n� i/r t:• `�r C r►l+ C_ .-e.«. b e ifar>^,
5b.Latitude and longitude in degrees!minuteslseconds or decimal degrees: L f��, �V c, Z�t�� s G "r i C
(ifwell field, me lat�lon�a=:u(ricicml 22.CertillcatitUl: �V C f !�' f
0' 73 N -aS'o. 2,3Z3�oy
SiIalauire i.,l'Cenilicd Wrll Cnnararu,r Date
6.Is(are)the well(s)O'Permanent or CffTcmporary
Hr ripniqe this Gaup/htnrhr rvrti/a rhnr du•,w•lll,,t,art. aed m nr<vre;¢rrr.
7.Is this a repair to an existing well• 01'es or JoNo ,nth I s;t NCAC nK'0100 ur I SA N('A'C 02C,nln0 11,41 V' 1,m++�ri+rn Srnririard.unrl thut
11 ihie,,a relxrir,fill oll,kuonn,rrll rnneuri<'tirur inlnrrnruinn nor!rcpinin the nat of the
rope nJ rhi.a r,,,wd has been prnridcd I,,'he nr•I!n,euer
re a w i+ndrr ell ra,nar•,.sc,Iwa nr tin the bneA nfrhn Inrn'_ 23.Site diagram or additional well details:
S.For Geoprohell)PT or Closed-Loop Geothermal Wells havint the saute )`ou may use the back of this page Io provide additional troll site details or well
con5lnic•liun.only 1 CiW-1 is needed. Indicate'fO7A1..NU(vIBIiR ul'wclls
consiniction details. You may also,attach additional pages if neeessarN.
SUBMITTAL INSTRUCTIONS
9.Total well depth bolo"land surface: —(ft-) 24a. For All Wells: Submit this form within 30 days of con)plc»on of well
F,v nnrliiplc err-lle lice rdi d pih,,l dilli•rr•it w,amph•.,(a 200"11nd?(n.100) construction to the following:
10.Static water level below top of casing: ,2 (ft.) Division of water Resources,Information Processing Unit.
1!nnrer keel i,nb+rae+rsu,•: use_,"• 1617(Hail Seri-ice Center.Raleigh,NC 27699-1617
11.Rorrholcdiameter: (in.) 246. For Injection Fells: In addition to Sending the funs to the address in 24a
ahove• also submit one copy of this form within 30 clays of completion of well
12.Well construction method: S•ti a✓r � construction to the following:
me atiger.rtaap-,cable.direct Pooh,eic.l
Dlrisinu of Water Resources.101dergroun(1 Injection Control Program.
FOR WATER SU1'1'L.Y WELLS(/N1.\': 1636 Mail Service Center.Raleigh,NC 27699-1636
13a.field(Kpm) 3lethod of test: 24c.For Wale"SDDtII\'C Iniccfion Wells: in addition to sending the form to
the address(ce) abnvc. also Sublilit'one copy of this four) within 30 days of
13h.Disinfection hype: Amount: completion of well construction in the county health department of the county
eh:n•constructed.
Re,iccd 6Fa,rot(iw'-1 Nnnh Carolina Dc•pannrcnt of l:m nunmc.✓ J..Jr,-I)it irlu❑of N atcr Rc'cuuicc>
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