GW1-2021-03055_Well Construction - GW1_20210624

WELL CONSTRUCTION RECORD(GW-1) For lnt,:rnaltiseOnly
1.Nkell Contract it iuj-ormation:
14.WATE.R ZONES
REG A 7F—RO%l -to I DESCRIPTON i
ft. ft. 11 C���
NC Weil COMM'3"t frS3110n R CASING(fur malts taxed w Is)Rt LINER(ifs pelicable)
n- �IR Secto" 420=111": TO DiAVIETERe! TAWKNMS i MATERIAL
'SER CASING OR TURI\G(egothbrival closed400pl
Jolo-6055,5 i—Wolvll' To Dl..,.%lvrER THICK ES
MATERIAL
2.MAI Coustrui,;iion Permit... in. ;:=Fip v--
boallappli,mi'lle 1;*at1i,Iilper,n?!,if.,.17C.ComiA. ia,wsiw-i'l, I -IQ ft, 2r- I-
ft.
3.Nii ell I Se icfic.: Cil use):
17*SCRVEN
Aan,ultural ; TO
ater Supply M ell: I DIAMETER SLOT SIZE 51ATERML
nmu !,public in.
(jecitherna!(I Cooling sup".1k.; M<sidential* ter SuPPIN (single) f..
in. f
lndust-naVCor..,,--.--! OResidential Water Suppl%tshared)
i is.Gizon*
rRom TO MATERIAL ENIPI.AC*ENIENT%IETHOD&ANIOI;NT
8on-%VatcrSur,:!. '—.H: I qC,Lk
.Monkoring, DRecovery ft.
Injection Well:
Aqu;-.er ikech; rlGrounamawr Remediaucin
Aquifer Stora�,.,- "ecOverN Salinity Barrier 19.SAMY(,RAVEL PACK(ifatiplicable)
f FROM TO MATERIAL! I E.MPLACEVIENTNIErHOD
Au-,&`er T"t 13Storrimater Drainage r, ft.
Fxp,mmenia; nSubsidencv Control ft.
10.DRIL.L.NG LOG(artach additional sheen,if necessary)
FRO%l TO DESCRIPTION 1;olor,hardness,ioillroti, grain size,etc.)
[30ther ,i"r,fam under#21 Remarks i
YA I
4.Date NN ell(s) cmll icled: 41 %Vell If)#
5a.Well LocaC.
Fac:14% lhNner Nc. 1D-*il:aPv1l,:::b1e)
ft.
:1.RE.N*.,,RKS
Coan1% Parcel ldenii fication No.i PIN:
ib.Latitudean—w—%"de in dri.1:-v"-niinutesisecondsordeciinaI degrees-
Cert','wation:
350,38l" 1.2. 04qrot Wo"
6.lswre)the or OTemporar) Bare
4=� 1/11 ,t 'I'vill -%I,form.I hef%,hl 11110F III,, wo.,AWIV,0IH1!M%:1rd fit'I'vol-dimce
7.Is thisa rep:3 f-:Ming tis t.1!: 0 Yes or
tifibl, . 'Ild'..Yriom alemillfiv nl fito
repair raid.-r 21 ."'U'm or,It III dit,,1--of 33.Sitci:agram or additional weil dezaik:
8.For Geoprobc M,i or Closed-Loop Geothermal NN ells Ila\ing tine same You mt;,\ .:se tile thack of tills naze to provide additional\ve!]site details or well
construction.or is nceovj indicate'YOTAI.Nl',MBER of\kelis derails. You rnoy also all additional pages i:'necessary.
driiivd' SI SUIT'!AL INSTRUCTIONS
9.Total well de-1 J M 11 �i, land suriace: 4A4-I-'
(ft-i 24a. For All Wells Subm,:i ,h!s %\ahm K, days O.'completion of well
1-firmull,ple 101i'l
,:onstrLlCl1.,l1 t0 the J*0110W1ll,:
10.Static water relou top w1casing: go (ft.) );vision of Water kesout-c'es.information Processirg Unit,
if ts-,Jfir to-C/I, 0•. 1"', 1617 Mail Service Ce tter.Ralel.h,NC 27699-1617
11.Borehole (ill.) 241). Foi niection NVells: in a Iaiu6n to sending the form to the address in 24a
e,air sabi-na one this�tGinan ktimin 30 days ol'cornpletiOn of well
12 y1 1ti:onsll.
it)wl,fifliom.ing.
ffivis;,,n of Water Resources,L uder2round Injection Control Program,
FOR UATER:- 1636.Nlail Service Center.Raleigh,NC27699-1636
ei
13a,Yield(a n,, ,_I) '14c• For\\ater Sunni%,& Inoection iVells: In 34di,.ion to sending the form to
�p Method of tcstl� Dig - * d
I '11C above. also summilotie cool, of glib l6m, witiliri 30 daYS of
131k Disinlecti" 10 f N"It Amount: -i -) rzinent of the county
�onlplc;;�-ii of conmru,:uc�n dei a
'Ailere C-!;%'UZtej
2-22-2016