GW1-2022-08176_Well Construction - GW1_20220505

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
JQr,n 14.WATER ZONES _-
FROlf I TO I DESMPnON
Wd1l Cottum Nun
NC Well CmtleadorCnlification Number IS.OUTER CASING(for moldtsed weft OR IMUM(tra e)
�l�(� SP YViC 4 S 1 I nC FROM I TO I DWAMR THICKNESS ►1AT>;1tlAL
k. I R. I in.
Company Now 16.MOR CASING OR TUBIIVG f ctased• )
2.Well Construction Permit Y:J i) P D - d 2 O FROM io I DIAMSIBR I THiCKNSSS atnTERI►L
List all applicable well cotutn(ction permits(i.e.UIC,Colauy,State,Variance,etc.) k. .96 a' (i• 2 f " 5D 2 Z 1 P V C -
3.Well Use(check well use): R. R. 'IL
17.SCREEN
Water Supply Well: FROM TO MMETER st.orsIZE THICKNW aIATEuu.
Agricultural �==ial
aVNblic ft. ft. in.
,C,othermal(HcatinglCooling Supply) Water Supply(single) ft, ft. in.
Industrial/Commercial DResidential Water Supply(shared) Is.GSOttJT
Irrigation FROM I TO H4T=tIAL 1 NiK AcLN1L\T METHOD&AAlot;�
Non-Water Supply Well: U k• }Igne PO t.rL
Moa➢toring 13Rccovery
Irtiection Well: �s
ft. ft.
Aquifer Recharge Groundwater Rcmcdiation -
19.SAND/GRAVEL PACK licabte
Aquifer Storage and Recovery 13Salinity Barrier FROM To JIkT1ERIAL EMPtACRIMM METHOD
Aquifer Test Sttxutwatcr Drainage
It. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach addkdeutal dterets if
Geothermal(Heating/Cooling Retain) Other(explain under#21 Remarks) FROM TO DESCRIFRO-N(color,huftNamainck tyg.gren du-ere.)
It. V L ft' 0. 6 v
4.Date Well(s)Completed: 4- iPb--;t a Well ID6 O ft' �YQ A t }2.
Sa.Well Location.
1 p 1 k. k.
FwIlity/Owner Name Facility ID#(if applic")
121 CI;ti- Roao1 PPhrdSC 1 NG 28'1(.0�Q -
Phyaial/lddreu,City,ad Zip
TNA���v�1ziry q5)4 U.RFMARxs `
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degas: _.•.y L , ���ry,ari(if well field,one lattlong is sufficient) 22.Certification: - r
MI 141 55.1121 N 32-0 -41' t44. ZG5Z211
W
6.Is(are)the we"(0 Permanent or [3Temporary Sipamm of CextiHed well Coattactor Date
By signing this f-,1 hereby certify that the wen(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or ONo w4h 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Wen Construction Standards and that u
1rlhir is a repair,fill out known well construction igforma►ion and erplain the nature of the ropy of this record has been provided to the well owner.
repair under P21 remarks section or on the back of thus form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SITRWTTAI,INSTRUCTIONS
9.Total well depth below land surface:- C) (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For malripte wells list all depths if different(example-3@2M'ead2@1Wj construction to the following:
10.Static water level below top of casing: Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1 c (in.) 24b.For Injection 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: Rc A-n_y-'A construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a,Yield(gpm) Method of test t 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection typet Of• Amount: completion of well construction to the county health department of the county
where constructed.