GW1-2021-00339_Well Construction - GW1_20210127

WELL CONSTRUCTION RECORD
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1.Aell Cuntractor Information:
14.WATER ZONES
rROM TO DESCRIPTION
a , 3s- R
Connacta:C<rtiflcauon Numetr FAO04 CATO SING for mR(d-cooed wetLs OR LINER ifa 'abkl
FRN DIAMETER TX7CK.NE55 M.ITERiAL
itrl 1 o 11 1 97 f° (D 114 la i- DM I PVL
('ompam Sa:r. 16.1NT'ER CASING OR TUBII+i thermal closed-toe
I /� Q f"�• EROM TO DIAMETER THICKNESS )f
2.Well Construction Permit e: J o I f. j fa in.
inrn!lnpphtahh Lei nn...1,.cnr:,:pe.,me,o.e.('oannt 5'rnn.
3.Well Use(check well use): j7.SCREEN
}}'ate[Supply Well: : FROM TO DUIIETER I SLOT5t2E TXIC'KNEaS : MATERIAL
i' f... ft.
�A rp. �h cn ai/Pud1 = j .n
ee�z(, (Hen:ing/Ccckng Supply) 96c 'de va!Watr Supp'y(s+nale) ft. it. !
=induAna!iCorrme:c:ai ❑Residential+Water Sup ) 16,GROL'C
Fly(s!'A1Cd; MOM TO N/ATERLLL ENIPLACEME\T NI ETN006 AVOC\
ft. Qr fr. Cram\X rP
Yau-W'Iater Supply\\'all' h. f+.
NQ l f
� oniton rcng CRecove
Injection Welt: ft f.
ZAqu:frr Rechatgc CGrourdua:r. Rcmecia::on �i9 SANS VEL PACK�if apoliublel £Mrt_+ceNElTMerueo
FROM TO MATERIAL
.=AF::It:S:orzs!c 0.1c Rdcoven ❑Sahn(n Samer
[Act l',er Itsl Lb:Or:nN2f<[C:£r2?_: - ft.
CEzp<r.n•1cn1a!7" cirnoius:y -Suhs:dznce C¢-.:r'.
26 DRILLING LOG jn.z addinosul shee4 if etassary
_Gco:^.nrmdi(Closed Loop) ❑Tracer
' ' I.— j
' nae
—Gc ' •-'( 'c �C olmRen•n) �O:her(esp!ar=ode:d2! Remarks) ft. tinriu.etel
1
q,, f:. : ft. i
3.Date W'cigs)Completed: IQ, OG(�a
R.
i.\\'ell Location: h. f[.
rim ft.
:O p!:cabltl f: ft. !
►�IJIICI IW W� � ���QJ ft. � fc i
x,ro Zip 2:.RE.MARji3 -+
I ors 3523 - '16- (0015
<' Pa:al Irim:n::ea::o:e Xn (P!\)
5b. Latitude and Longitude in dtgrers/minutewseconds or dectrtat degrees: 22.Certification:
pi eo..Ieid,one!nt long:s euf6cmn:
a0ty
// �S:efulwne of Ccnif tat Well Ult-f-ACW
6. Is fare)the Nrli(s): @Prrmanent or [ Temporary X-si;u r (I,,!( u.l h rehl c h 1;,,,r , lily'.r. ! r
/ Wd�('R 1)('.Wit" 1.I.J(A(l cell n1111;l t lho'lrtthu llnt,r,
7.Is this a repair to anesistingwell! ❑Yes or ANa .{'fr'JI•, e,:nt hn.nr y 4
rr - /wrn Fll (a Il :a/nnnon end erp ,c.:ax•n'rj the
7m:,.. 235ae diagram or additional well details:
Yo.. ^a) -.se he back o n.s age 10 P ovide
A Number of Melia[onsirueted. =,s:�.;ctmr details Yot ma) ;.;so auac:t addi::cnai pages If iwcaoia :
1.a..... pi: u....... r...errn.+,v.r vyp.+.i7.q\'!J orb,Oeanme:on,frornmr,ti..c nu
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27.Submittal Instructions'
.crm:r n,v l:aa;
9.1,0121 well depth below lend surface: I LFS (ft.) Zia. For All Wells: SubmC lhls fXM .c',Ih.r. 3U cols
Pormul(yJe e,�icfu(nil JeprY,.4drllercur[esmuply.3ry21r0 and 2G7 ibis') COnstrueuOn in life fo!i0Wut4 .
Division of Water Quality, Information Processing Lail,
10.Stafic water level below top of ra Q
sing: L. D (ft.) 1617 Mail Service Center,Raleigh,NC 27699.1617
::..::1. .
Borehole diameter. l� 3 (in.) 24h. For Injection Wells :n a(ld-:t on to se dine Ind for"- ,o .c abutc5l.n 2s
above. ciao sconit a copy o. ,,,a !o[m v-IIh:r 30 days of .,inp( (c. o! 111;.
:L\\'ell construction metlrod: An fin l/ nsuuCl;cn to Otc 500 rng.
..c 1.lit.ru;a) able.cr«:push etc
) Division of Water Quality,Undtrground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 21699.1636
13. FOR WATER S('PPLI'WELLS ONLV:
23c. F Witte Iv S o &Geothermal Wells: In add:nan to sending Inc faro lu
I3a.field/['Ploy Method of test:+e-`A the address(es) above, also scbm:l one copy of this form w:m'•n 30 deys of
comietlen of well consaucrar, m the county health d<panmert of file ecunty
1 13b.Disinfection type: �'3�QC{Y1P_ Amount:_— p
where constructed.
form UI\'-t �nnh Carolina Ccp:nmcr.:of En.ironmcm anL]arur.l aeswwu-Divsian u!\l s<:Que:ip
:Ae.sea tan EU:3