GW1-2022-09771_Well Construction - GW1_20221027

Print Form,,
WELL CONSTRUCTION RECORD(GW-I) For Intemal Use Onl :
1.Well Contractor Information:
5 A,"50 X-1 • - '•- • . 14.*AThRZANES
Well.Contractor Name z FROM .fUa�.
ft
DE SCRIP
NC WCII Contractor CertificationNumbar s, ----
: 15 OU.,TFR GAS1NCv;for.;mtilh�ased v ells OB LINER ifa` licable
' 'iy -G s u• t om,, r• t FROitl !._ rO--- i- DIAIUETER TEIICI RSS - M,ITERIAL ^
Company N�anieJl.1 Y ---3..Y 1�, ! f1 r t:t'ffr -,. ln. - --
" _J A6ANNMCA8INGt0RTUBING oeotlicrmalclosedloo i•- -
2.Well Constr'oction Permit#: FROM1f 1,TOM DIAAfETER TEHGICNESS tiL1TERIAL_
`List al/a'ppllcable well Gansu ac urn penntts t e G!C "' r - - — "(' ConntyxStati I ariance,etc) _
3.14ell Use(check well use) _ •.._._. i ft: - ft:
_ 7 in: -
t7g REEK `;-
Water Supply Well: '.. •. a • ,,
PROM1f TO - DIADIEFER SLOT SIZE THICKNESS 3fATERIAL
Agricultural ' Municipal/Pdblic ft. Ct. in.
Geothermal(Heating/Cooling Supply) Qlt6sidential Water Supply(single) ft.
IndustriaiJCommercial 2esidential Water Supply(shared)
IIrI ahOn FROM TO MATFRIAL, EAIPI>CEAIENT:METHOD S AMOUNT
Non-Water Supply Well: ft. s ft.
MonitoringEiRecovcry Yt. ft.
Injection Well:
r't. ft. .
Aquifer Recharge nGroundwater Remediation
19rS VD/GRAVEliPACK;(ifa licablc"
Aquifer Storage and Recovery DSali"nity Barrier FR041 I TO JYATF,RIAI. .�` F.MPLACEDYF,AT MF,THOD
Aquifer Test [3Stormwater Drainage fL ft.
Experimental Te"chnology OSubsidenee.Control ft. It.
- geothermal(Closed Loop) ElTracer 20: I L^LING°LOG.attach additional.sheefs ifmcessf
Geothertnal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To - DFsctuPTloN'(�olor,nardnesaaaivruck t _G rain siZF ete.) x._
L
��••°°�� ft + ft
4.Date Well(s)Completed 'O ? We11,ID# _ < -Ct it_ i
_r
5a:Well Locahon -'
Facilfl/OutnerN c ' - "' I ---
Y Pacilit uID (ifaliplicablCl
y
LCr
Physical fA ddress;"City,and 7tp ft Ct -.---
2IREMARKS _"w._
County Parcel Identification No.(PIN)
. . iflwi'rl"w'j+t�'1 f�.':.:•r:.u>i:':r.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient)'
22.CCrtification: _
6.Is(are)the well(s) Permanent or OTemporary i atdre ofCcruticd Well Contractor Date v
r I By fisying this f mit,I herehr cerlifv that the rsY116sLtvas(rrere)_constructcd in_acerrdonee -
-7.Is-this a r�p::irtn an: sistimg :nli— Yes. rr Tyu - �"` lraft tS FNt1IC 02C.0100'or iM A+CAC QC.0260 Well Coiunrrcrian Standards and that a
Ifthis is a repair,fill ma known well constrnctimr ir0arinarian not Grplaia.tlre naturenJ)lrr cope of this record h¢r been provided to the hell owner.
repair under 1121 renrarb section or on the back of this form. I
i 21.Site diagram or additional well details:
8.For Geoprobe/DPT or.Closed-Loop Geothermal Wells having the same
ou dray use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate,TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: rr t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:a i h) 00 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple hells list all depths ifdierent(example-3@200'and 20N00') Constr tction.[o the following:
CDC)
t
10.Static~valet level below top of casing: t (ft;) Division of Water Resources,Information Processing Unit,
If water lovel is shore casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: P (in.) 241).For-Iniecdon Wells: In addition to sending the form to the address in 24a
,�� t JJ 1 abnveI also submit one copy of this form within 30 days of completion of well
12.Weli construction method"AL l.$" 9`_. tl construction to thc'following:
t c au er,rotary, p('. . g tary,cable;direct wish;e1cJ
1 Di(ision of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 31nil Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) t Method of test: All 24c.For Water Suably&Injection 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 type: Amount: compli tion of well construction to the county health department of the county
where:constructed. j
Form CiW-I North Carolina Department of Environniental Quality-Division of Water Resources Revised 2-22-2016
:
!