GW1-2021-07167_Well Construction - GW1_20211006

\_�Vii t L L U V N D I n U V IU r l t u u nu I U VV-i) For Internal Use Only.
1.Well Contractor Information: f
l e,C Y"(A RR-e,r p 1 14.WATER ZONES
WellConhaetotNam FROM TO DESCRIPTION
020'1 R -14 n -1 n
a31 It. a4p n 1 t Arts
NC Contractor CertitificationNumber 1&OUTER,CASING:for multi-e=dmel R LINERi rf"" linable -
FROM TO DIAMETER THICKNESS MATERIAL
20-56A3
1).5,d- e!16. --r-poic. W A +I n r ,I n 1 C,'j in. SbP 21 FPS C..
Company Name 161NNER CASING OR TUBING(fledIftrinalclosed-460PY
2.Well Construction Permit# FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable[sell construction permits ff e.1110,COMW,,State,trariance,etc.) fL ft in.
3.Well Use(check well use): tL fL to.
Water Supply Well: FROM REEK 0 DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural DMuoicipaU iic n n in
Geothermal(Hc h g/Coo1.g Supply) ffKmdenhal Water Supply(single) n It. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
'JInigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: () fL
0+ f Yuma _p_-63'"-_/O
Monitoring DRecirvery n n ? G K-r 717
Injection Well: n ft.
Emal
Recharge DGroundwater Remediation
19 SAND/GRAY PACK rf licabl
Storage and Recovery DSalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Test DStormwater Drainage n nental Technology OSubsidenee Control fL 1t.
mal(Closed Loop) Tracer 20c DRILLING LOG attach additional sheets if necessa eatin Coolie Return 0ther(explain under#21 Rema&s) FROM I TO DESCRIPTION color,hardn milfrock WM grains etc
go n 35 n 015
4.Date Well(s)Completed: (n'i q-ZJ WeII IDS 35 It Sol n S Q le
5a.Well Location: 01 It. a fL %Af1 TIN
I)aMie.L Sc�enKtr,r-&n ft. n
Facility/Owner Name Facility IIJ#(if applicable) n n
CD Ir-
1514 ;:S6\-%nsrn, �Mi ll fJahal►Ia i�1C._ n IL it
Physical Address,City,and Zap ft. ft. r�g1n9
DurHoyn tC1O13/_ 21.REMARKS
County Parcel Identification No.(PIN) `n
5b.Latitude and longitude in degreesfminutes/seconds or decimal degrees:' 4
(ifwell field,one Iatilong is sufficient) 22 Certification:
lu W x/ (n- l7-z/
6.Is(are)the well(s) rmanent or DTemporary Signature of Ctifil Well Contractor Date
By signing this form,l hereby certify that ffie wall(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or EK0 with 15ANCACO2C.O100or15ANCACO2C.0200 Well Construction Standards and thata
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to ffie well owner.
repair under AV remarks section or on the back of this form.
23.Site diagram or additional well details:
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
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: —I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 02 24a. For All Wells: Submit this form within 30 days_of completion of well
For multiple wells list all depths ff differerd(example-3@200'mid 2@1001 construction to the following.
10.Static water level below top of casing: lJ (ft.) 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: fJa (in.) 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,rotary,cable,direct post,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ^^ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) l J Method of test: /-*s•%r 24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HT 1-4 Amount: VZ I b• completion of well to>�cti,to the countyhealth dent of the county
where constructed.