GW1-2022-10808_Well Construction - GW1_20221209

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1.Montractor Information• 1403u��1 17
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9 A S 6 V l 14:rwATERZONES
WcUCoatractorName FROM TO DESCRiPTI4Hyy�
ft. ft � //'1 1
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NCWellContmctorCettification Numb er J/�/� Y150UTER:CASING toeiiinitieii9id.ivells ORZiNER fe"'liEable";S%• !
FROM I TO DIAM n[EIER I TCIINESS b TERLAL
CompanyName IAIJ ft 14 4 1 i d if
3 �l 16:�IPUMCASINGORTUBING:'eStbtimsleluiedan
2.Well Construction Permit#: FROM -1 TO I DL4AMTER I THICMESS MATERM
List all applicable ivell construction permits(te.UIC,County,State Variance.eta) ft. It, in.
3.Well Use(checkwell use): ft. ft. ia.
Water Supply Well: 1T.SCREEN3.cs`° 81
FROhi TO DIAMETER SLOTSME THiEMMS hiAIERIAL
Agricultural �MunicipaUPubGe 0 ft, tt In.
Geothermal(Heating/Cooling Supply) Wre idential Water Supply(single)
ft tt
htdustrial/Commercial �' gll�esidential Water Supply(shared)
--.._ •2� 't•'�� YIS:GR�I1Tl.°!Lrt�.i.:{=. ;r i!Ij:}.'.ii:.e:,`':' : !C ..';:}`f ism'._1'i•.Y"ira``•iik:'15°_hu�a4.•.:+�
IRi atioA r Q .8 a iyi FROM TO TERiALf ]S;AMETFIOD&AMOUPI[
Non-Water Supply Well:" 9 2�2 0fajgg ft :Monitoring Recovery ft ftInjection Well: �
AquiferRechare MFGroundwaterRemediation
vIY' s= i 7 :r19 SAND/GRAVEL•PACic r!a`li@ab1E stl::?,tq^2 t:.%".::".S...', ::ii t':.'S='i'••''i;✓;%
AquiferStorag9andRecWerp� [3SdinityBanier 1�/;,,
o hrATERur, EMPrr►cEhiQrri►sErHOD
_.. AquiferTest ElStormwaterDramage ft i1
Experimental Technology Subsidence Control fi
Geothemral(Closed Loop). Tracer LOG attaiLadditioffidA N'ifrieen� r,:>,;x ;,R 0:•.,,:;:,_;:_
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_. Geothermal(Heating/CoolingRetum) Other(explain under#21Remaiks) O D CRIFnON eolannardnemsaium k ,elm)
J & Lt
4.Date Wells)Completed://`- Well ID# , ft B Dlt/
Sa.W IlLoca n: IL `p
��PAe".r . ft oos o �v
F3c0ity/OwaerName Facility MY(ifapplicable) ��Ly/( ft LO y,/ y,-p
Physical�Add �.City,andZip f�t���V�V fl �'7r1 t1�a'.51ttt�at{fA :i•i• :}}}��: '_G.JY::�,:J•,(:'�:�7�(y�:;.tiP. ::5':�.'i.t1:l�7 w{ :::%:•�:�S iy::
County, •Parcel IdentificationNo.(PIM �' Y7• Ago PA&g~
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latilong is sufficient)
22.Certification:
3j5,; N eo" ),
6 Is(are)theweil(s) neat or OTemporary SiVaturcofCAMedWellCoutractor Date
i
By signing this form,I hereby eerdfy that the iveli(s)was(were)constructed In accordance
7.Isthisarepairtoanexisingwail: []Yes or Wo svlthISANCACO2C.0100orISANCACO2C.0100WCHCombuctlonErmg rdrandthata
Ijthk Is a repair,fill outImoim ivell constructionWarmation and erplain the nature ofthe eopyof thfsrecotdhwbeenprovidediethe well miner.
repair under021 remarks section or on the backofiftform
23.Site diagram or additional well details:
8.For GeoprobelDPT or on
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 TOTALNUUBER ofwells construction details. You may also attach additional pages if necessary.
drilled' ..0 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �O (m) 24a.For All Wells: Submit this form within 30 days of completion of well
For tmtltlple wells Its tall depth stjdYff-ent(earample-3Q200'and 2Qa too 5 consirtictjonto the following:
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10.Static water level below top of casing: / (ft) Dlvfsfon of Water Resources,Information Processing Unit,
ljwaterleveils above earin&use••+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: I (m) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:/ ��7I6' above,also submit one copy of this fors within 30 days of completion'of well
(Le.auger,mtary.cable,directEmb,etm) " construction to the following:
DIvision of WaterResources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) d v Method oftest 24c-For Water Suonly&Infec6,n 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: �� completion of'well construction to title county health department of the county
where constructed.
FormGW-1 NorthCamGnaDepartmentofEaviroamentalQuality-DIvbioaoEWater'Resourees' I Revised2-222016
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