HomeMy WebLinkAboutGW1--03290_Well Construction - GW1_20240603 94ite,4701__
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WELL CONSTRUCTION RECORD For Internal Use ONLY.
This term ran be med fir single or matt:pie wells -
L.Well Contractor Informadon:
14.WATER ZONES
-C, (:) V.• Al iS i. )7(.1 4'7( FROM TO orscitirrioN
7 W
vv.:II-Contractor Name. r '
ft. rt.
NC
15.OUTER CASING(for multi-cased wells)OR LINER(if ap•&able)Wen Contractor Certification Number
FROM TO DIAMETER THICKNESS MATERIAL ,
McCall Brothers, Inc. ft ft. in.
Company Name 16.INNER CASING OR T:BINC,(geothermal closed.lanp)
FROM 1 TO DIAMETER TRICKNEMI MATERIAL
2.Wen Construction Permit#:itC 2 7,...? 0 it 1 1 ,10. ,. ti 75' I VC_
List all applinoble well construction permits tie.Coondy.MaI *? ,',once,or,
ft. 1 II. tn.
3.'Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOT SIZE omit:NESS MATERIAL
ft. ft, In. 1
Li Agticulteral UM unm icaVviihlit
I: .
Geothermal(BeatingiCeohng Supply) rgfritienfial Water Supply(single) ft ft. hi
ClndmarialiCommereial °Residential Water Supply(shared) FISR-0GmROUT To
I:Irrigation I MATERIAL
4.3 ft.,b1 z ft. /./ EfdElACEMENT METHOD&AMOUNT
114/1/>4 GI 4i-a4A ift Y" frie frit
Non-Water Supply Well:
ft. ''''''' it
E:Monitoring °Recovery ......
'in action Well ft. tr.
I:Aquifer Recharge OGrotintiouhT Rerneniation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT NETIIOD
L.:Aquifer Storage and Recovery OSalinity Rai ricr ft. ft.
••-
C.:Aquifer Test CIStormwiner OTainage ----",
ft,
Clisperimental Teehmilogy C1Subsiduricr C4ritrol
20.DRILLING LOG lAttatli additional sheets if owessaryl
r(iontlicnnal(Closed Loop) DTracer FROM TO DESCRIPTION Ogler,luerdittu,siall/roi-k type,grid stir,ift.)
DGcothcrmal(Heating/Cooling Reuitn) 00ther(exploit]ander 421 Remarks) 0 4` /7 It. 0 vZ it_ 3
ft rt.
4.Date WO(s)Compkted: 4/— I., / i
i i_.2.ft. i -7 ft. A
LS A o LA
'
I) ; P—t
5.'Well Loeatkuft .,,,c- ;--717 .-24.1-'". ti :4-4-
61,6,',Lay Airmo&i.ti- /a 2 F3 ,--ft. Id.,,.., ft. . t 1
ninthly/Owner hltme eaohly ova of appiteahlo) '7- —p---t--- 0
11-
6, 41.)/z.-e_siegitre p e goevA/4,lei f 60 7 Rhyq teal Address,City,and Zip
31.REMAR
/.1./AV*1.111.39.4" 020t1,3 -`'.44/6... •. ,..
Cooaty Maori 1r1,,infication N .(PIN) l.i 4 - L-
5b,Latitude and Longitude*degreetholtiutes/searld or decimal degrees 22.Certification:
(((well field,one(at/long is sufficient) % -.. , .
i ....-.
6
0 ij-.‘ ei /air N t/Jsr -,/,_ifol 17( NV s))uftmil.„eZ__
- :nn;&tent:*i Well Contractor Date
6,la(are)the well(i): ClOc.rmaneut or LITempora i y fir signing this nowt,I out certO,that the well(s)11,43 Owe)comitucleil in accordaoc e
with Ill NCAC OW.0,00 or I YA NC4C 02C 4200 Well Canrauction&watt,d, and that a
7.1s this a repair to an existing welt: QV es os d.:i('''.7n oopy of this wooed has'wen provrded to the well owner,
Inhtv it a repair,fit/out koala:welt eAnstrunthin intreetatior:iId,,onion the ovate if the
repair under All remoras sea**or on the hack edits for*, 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
a.Number of wells constructed; / construction details. You may also attach additional pages if necessary.
FOr maitOle*Mon or nort-water supp4,oath ONLY with ar sante ontiirucrion.1^,iti elm
submit weepers 24.Submittal Instructions;
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this tom within 30 days of completion of well
For woinpie wells al all depths fide-prow(exa e.3421.0'MN/.21i l',i ilo construction lit the following:
10.Static water level below top of casing: 7 0 (ft) Division of Water Quality,Information Processing Unit,
lf woter levet is above casing,use"-'' 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: X Yfi` Om) 24b.for IniectIon Wells: In adddion to sending the form to the address in 24a
abov also submit a copy of tilts form within 30 days of completion of well
12.Well construction m 4 ethod:i /14 IM..2,1 k _ consue,l:dial to the following:
'Lc.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
IFFOR WATER surrE,v WELLS OK,V: 1636 Mail Service Center,Raleigh,NC 27699-1636
ji . ,,,,, i
'/-5‘.- 24c.for Water Supply&Geothermal Wells: 1.1 addition to sending the form to
1 13a.Yield(gpm) /1 __.., Method alert: f-,!.!c-tc._T,..„_/.."
the address(es) above, also submit one copy of this form within 30 days of
i 1311.Disinfection type:06vej& A nr, i, c.7___ coin/stet:ion of well construction to the county health department of the county
' N where constructer].
herrn CiW-I North(%.1.4,i.); I,!,,,nner...I,f knvironment and Natural Resources..Dmision of Water Quality Revised Jail.2011