GW1--03947_Well Construction - GW1_20230612

WELL f
CONSTRUCTION RECORD(GW-11 Fur Internal Use Only:
1.Well Contractor Information:
Well Cuntrtclur\an!c FRO:I TO AF.SCTUPTION
144,14/ - �ft. 2Grft. _cod
ft. ft,
tic AVd!Cc,naCertiticatiuto Nunillc:r 15.Of.'TER CAfiLNG'for tnultf-cord ts-ells)OR LINER(if aa,I:cahie)
FROM TO bIA12t.'IEIt 'I7i1CK:VI55 MATERIAL
� ? pikityNtoing0 ft. , ft, ,x? in. sz:nor 4,v
Company Name ,/V nu,,_
I��� a /t 16.INNER CASING..OR Tit:?ING TEttiternrs,lceased-li) f2.Well Construction Permit#: �/ FROM TO DIAMETER THICK.NEss rATrRIALI.Ist ell applicohle well construction pVIN5WEir
uts Ii.e.VIC,County,State,parlance.crc.) ft. _" `
3.Weil Use(check well use): ft. U. in.
Water Supply Well: 17.SC,REF:d
FROM TO DIAMETER SI:OT SIZE THICKNESS MATERIAL
Agricultural �i nfcipal/Public � t. •r�G'fr. 2 in. 2 o �� ��y
Geothermal(floating/Cooling Supply) esidential Water Supply(single) ft. / f:, t.
$:Industrial:Comnrercial 0Residential Water Supply(shared) 18.GROul.
(Irrigation FROM TO MArERIAI. f EMPI.ACEMeE'FMET10D R AMOOvr
Non-Water Supply Well: ai ft. tr ft. 41t/J7�� �JG,,., "
'tMonitoring Recovery ft. ft. 6��
Injection Well: [� r_
ft: ft.
,Aquifer Recharge ®Groundwater Retnedicoon
19.SAND/GRAVEL.RACK(II auplicaldel-- jAquiler Storage and Recovery DSalinity Barrier FROM 1 TO j S9A1TRIAL I EMPLACE\1F.NT METHOD y
Aquifer Test OStormtvater Dreinagt' fu 2 G,r"R. �^" f -{ "0.-
Experimental Technology ®Subsidence Control ft ! ft- !T /r !I
I
DGeothermal(Closed Loop) DTracer 20.DRILLING LOG(roarer additional thesis if neeessorv)
FROM 'r0 DESCRIPTION Rolce.hardaess,coil/mac type.train size.etc.)
tJGc-otlterntal(Beating/Cowling Return) rjOther(explain under tt21 Remarks) ff
Le fr. `2 ft iJ >iiarr
4.Date Well(s)Completed:LY tl Well ID# 1_r7 ft. r2 ft.
5a.Well Location: '7 S ft• z"/ ft. j/
C/OVVIII CiLl/triari V •,.4/. el, II- eAr, ,..): e/f---:, 7 if-%f.7;1 IF--r-,N,
Farafityio ne . Facility IDy(if applicable) ]e/ft. 7 ,ft. S / ,3 >�i Sy .
.�Yg ,�//y, e �( �g1q�-/- a�� It � ���
3 -- E 4"61J6V • �0 �!v _ ft. ft. MIN i_2--L-1.t-L_3
Phpsae r\dc;tens,City,and Zip it. ft.
OA rli
21.REMARKS 1 Ufa^.r°Mf<S�ld, l
County Ran:ef Identification N .(PIN)
v'fati. CAN1 y dW OvS
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: C5/112
(if well field,are lat/lo0g is sufficient) 22.Certification:
js�i �'�If . ..
N W Alta L l ,� J yJ)
6.Is(are)the wells) Permanent or Orfemporary Signature nature a Certified Well ContractorDote
By signing this form,1 hereby entity thin the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: f Yes or No with ISA ACAC 02C„NW or.15A NCAC RC.0200 Well Construction Standards and that a
if this fs a repair,fill our katowrt well construction information avid explain the nature of the (°p1'of this record has lice!,prcvtddd to the well owner.
repair under fr2.1 remarks section or art the beck of this form.
23.Site diagram or additional well details:
(3.For Geoprobe/DPTor Closed-Loop Geother al Wells having the sane You may use the back of this page to provide additional well site details or well
construction,out rC)TAL NUMBER of wells construction details. You may also attach additional pages it necessary.
dt Ailed:_ SUI3MITTAI.,I NST?UCTIONS
9.Total well depth below land surface:- f 4;7 (ft.) 24a. For AU Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(e.Ymuple-34r 200'mu/2e l h0') construction to the following:
10.Static seater level below tap of casing: s7 (ft.) Division of Water Resources,Information Processing Unit,
if sorer level is above casing,use .. f 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)_ 24b.For Injection Wells: In addition to sending the form to the address in 2da
if 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.anger,totaiy,cattle,d!rc...t push,etc.)
Division off Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
T
13a.Yield(gpm) Method of test: t1 24c.For Water Supply Er Injection Wells: In addition to sending the loom to
n� f the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:f-1(.54.v Amount: P) CZ completion of well construction to the county health department of the county
where constructed.
Form GW-I ,North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2.016