GW1-2022-00290_Well Construction - GW1_20221222

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.well Contractor Informatiolm
14.WATER ZONES
Well Contractor Name FROM To DinCYQfioN
NC Well Contractor CattHation Number Is.cauTm CASING marmnm<nsm wens OR LINER a cable
/rlti 4 { ^/I r FROM TO mAMBR 1R TmCnNESS I MATERIAL
Company Name �/)
2' 0330' FR INNER CASING OR el
2.Well Construction Permit fi FRost To n1AMsrsa 't'm MAT�uL
List all applicable Kell construction prr�iR(I&I Gllta/JI,,Iar.lbimoa,nsp R. R in.
3.Well Use(check well use): R I k. la•
Water Supply Well: 17•SCREEN
PP Y FROM To DIAM M" I saver st2R I Tanciao 4 MATRRIAL
AgriculNral ® IcipaVPublic G R- R. in.
Geothermal(HeatinglCooling Supply) esidential Water Supply(single) k. k. is.
[ndustrial/Commercial DResidential Water Supply(shared) I&GROUT
'Ift-rigation FROM TO RA/PIA N6ITI &"OUte1'
Non-Water Supply Well: k' 1"1 h" ?�(r^
Monitoring - Recovery k. -> IL > � p t n
Injection Wen: •• `'
rt m /C- Aquifer'Rechuge Groundwater Remedietion 19.SAIYD/CRAVEI.PA
Aquifer Stumge and Recovery ©Salinity Banier PROM TO afa OUEACRnfENr METHOD
Aquifer Test [3Stornwatef Drainage k. k.
Experimental Technology Subsidence Control ft. fLi`
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets R
Geothermal(Heatin Coolin Return Other lain under#21 Remade FRwt To DESCRIPTION leemr,wrdn�,wv
.
4.Date WeR(s)Completed: I Z'3'ltaG7►e�ID9 Q' R" CIO
Sa.Wall Location: R` L
R. IL
Faoilityl)wna Name Facility MO(if R' R'
Phya' Address.0tNaod Zip 7- fL R. ntcrsr,3«i�'1 Pry_-3:Ra:.�U0
31 �7S>
Eric
County Pa No.MM , Aix
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if welll field,on:balking;is sufficient)36_!t')45'3�� N - 7"). iZ11 3 W /J ��� �! '7 ✓�� �
6.ts(are)the well(s) Kent or Temporary Silloaflue of Certified WerConlrb.4m Date
By signing this form,1 hereby tarn•that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or DIo with 15A NCAC 02C.0f00 or 15A NCAC 02C.0200 Well Construction Standards and that a
ffthis is a repair,fill ll out known well canstruction information and explain the nature of he copy of this record has been provided to the well owner.
repair under#21 rernrks section or on the back of this form.
23.Site diagram or additional well derails:
S.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
consurta ion,only 1 GW-I is needed. indicate TOTAL NUMBER of wells Construction details. You may also attach additional pages ifnecessary.
drilled' SUBMITTAL INSTRUCTIONS
,J
9.Total well depth below land surface: '�/ /:l (ft.) 24a. For All Wells: Submit this farm within 30 days of completion of well
Formuhiple wells llstalldepths fdiiJkrent(esample-3®200•ald261001 construction to the following:
10.Static water level below by of casing: ZA (N 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. V y7 (has 24b.For Infection 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: �� construction to the following:
(i.e.auger,rotay,cablee,,didirectho push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
/7 I
13a.Yield(gpm) .�� Method of test: �ILt�+l7 `11i'i 26c.For Water Supply& Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: >—/ // / AAmount: r QL jellit completion of well construction to the county health department of the wanly
where consWcted.
Fo:n,GW-1 North Camliu Department of Euvimomcvtel Quality-Division of Weser Rcius s Revised 2-22-2016