GW1-2022-00286_Well Construction - GW1_20221222

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WELL CONSTRUCTION RECORD(GW-Il For internal Use only:
1.Well Contractor Information:
14.WATER ZONES
FROII TO DESQt}PtYOy
1Vcll Canuactor hmnc
Z
NCIVell'Con`tractorCertificationNumber 13.p,UTIMCAMGdbrmuld•casedwea O1ILi Mfifira 1ltatcle).
t C -e S , I h �' FROMTo DlahlE7EB TtRctt htATIsBIAL
ft. It. in.
Company Name 16.INNII1 CASING OBTi[lSING t eotbetmal clasedloo )
2.Well Construction Permit 6: S W eQ 6 _3 anent TO I DIAME'M I MUCtrNM MATrRIAL
List an applicable well construction permits(i e.U1C.Coalev.state,Variance,etc.) 6 R' I t> O' L l S !4'
3.Well Use(chech well use): D' B. in-
Water Sn 1 Well: 17.3CRF.EN
pp y FBO1i TO DIAMETER SLOTSIZE THIC6INFSS hLITF.RIAL
A .gricuinirat DMu tpnl/Public
Geothermal(Heating/Cooling Supply) Dftcsidcntiai Water Supply(single) R, ft. -
lndustriallCommerciat DResidential Water Supply(sbated) IL GROUT
ilTl at30n FROM TO hfATEMAL ENIFLAMt&MMt'sTHOD&AAtO[rNr
Noa•Water Supply Well: CDn• -0 h• &kh-'k eCkAx—
Monitoring t Recovery ft. ft
hrdection Well:
R ft
quifer Recharge DGroundwater Rcmediation
I9.51ANDlt,RAVELPACK hirable
Aquifer Storage and Recovery E3Salinity Barrier FROM TO ZIMTERIAL E MILACLIIUNT MEMOD
AquiferTest DStormwalcrDrainage
Experimental Technology DSubsiMence Control ft. ft
I�
Geatbcimal(Closed Lapp) DTmcer 24.DR]IjMGLOG(ettaehadd[tlonolabonsff
- Goothetmal EHcatin ICoolin Return) Other(ex lain under d21 Remarks) FROM TO DFSCItIPTiox radar rtardottr soilhatk sire ere)
sr. p e. C Ia O VC rI--(rd spy k
4.Date Wells)Completed: 17 - Z)- ZZ Well IDg 110 D' R'
So.Well Locations
u L C AYOA kyAF} M fr. ; ;`"£ ,t_�..a �{ t a
dam...5 '�� y�-L,.:+
rnci ity/ownerNomc Facility IDS(ifappticable) G' EL 1; r/.
118 Ewa t:i, Fs f�}ts p r• Mc,K�a►'I NG Ir.
Physical Address,City,and Zip I ft. R. Pr^cJr.�.;l Uri
Mr-• wr-11 OG f!9 QQG.7 R TIT(0 �•REMARKS
County Parcel Ideat;f�cation A'o.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one iatlloog is sufficiera) 22.Certii'ication:
35c, 3; r42 .3j-11171I/N � {' 2l•93r.4gzl/ W . 2
l.2-a 1 -tea
6.19(are)the wells) errnanent or Temporary ignature of certified wo Contractor Dale
By signing tttlsform,l hereby e-Ify that the waff(s)was'(trere)consrucred in accordance
7.Is this a repair to an existing well: Dyes or O nirh I5ANCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a
If Uds)s a repair,fill ant/at6H7t well constructian informatron and esplaht true nature of the copy of ttiis record has been provided to the welt owner.
repair underOV remarks section oran the bad(of thisfotm. 23.3;te diagram or ndditi(mot well details:
S.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site detours or well
con3umlion,only I QW-t is nccdcd. Indicate TOTAL NUMBER orwcns enrmti teolon detm'ts.You may nka awwh additional pages ifaeeasoery.
drilled: cctttn7iTTeT.x]N4TRLtt"t tONC
9.Total well depth below land surface: 5 iR) Ztta,For All Wells: Submit this form within 30 days of completion of well
For multiple trells list all depths if diJjerew(example-3Ca 200'and 2@I09) construction to the following:
10.Static water level below top of casing. O (ft.) Division of Water R I tunes,Information Processing Unit,
if nester level is abort casing,use.,"+" 1617 Malt Serylce Center,Raleigh,NC 27699-1617
11.11orehole dlameter: (0. 2 S (in.) 24b,For Infection Wells: In addition to sending the form to the address in 24a
12.well construction method; a shove.also submit one copy of this form within 30 days of completion of wall
- �O Law construction to the following:
(Le.auger,miary,cable,direst pails,etc) O
Division of Water Resauir Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 16036 Mail Sel i Center,Raleigh,NC 276991636
13a.Yield fgpm) 1blethod of test: ct'a� . C6 n+.m rack 24c.For Water SIDpIv&IpI!in We L; 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: C h) y; . Amount: S completion of well construction to tba county health department of the county
where constructed. i