GW1-2021-07262_Well Construction - GW1_20211006

t L L L U NJ I r1 U 1, I I U N M t 1,U Ct U I l7 W-I 1 t•or intetria[Use Only:
1.We ntractor Infor
• 14.WATER ZONES i
Well Name FROM TO DESCRIPTION
fL
7L
NC W Contractor Certifiratian Nmnber J `�O J� I u J ,
�S 15.OUTER C SING c multi-cased wills)OR LfNfR;It finable. .
FROM TO DIAM ER THI K E MATERIAL
ft. ft. I[L
Company Name nJ O'"
16;INNER-,CASING:OR1 BINGIdedtherifialclosed=loo
2•Well Construction Permit#: FROM TO DIAMETER_ THICKNESS MATERIAL
List all applicable well construction permits(a 111C,County,Start Variance,eX) It. fL in:
3.Well Use(check well use): ft. ft In
Water Supply Well: ROSLGREEN 0 DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural capallPublic ft. ft. in,
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft tL in
Industrial/Commeacial [3Residential Water Supply(shared) 1&GROUT
•on FROM To ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O it. D`E' n t.Rr� O)AIng d
_ Monitoring 011=very n- fL Sr4tJD G a: ��
Injection Well: It N- �d f s
gaifer Recharge []Groundwater Remediation O
19•SAND/GRAVEL PACK If licable
Aquifer Storage and Recovery [3Sadinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test OS10ru water Drainage It. fL
Experimental Technology oSubsidence Control n• n-
_ Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach addiHonalsheets'ffnecessa
Geothermal(Heatrig/Coohng Return) nOffiff(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnas,saiVroek grain Sim rdc
fL fL O
4.Date Well(s)Completed:_ Well ID# tL S tL
5a.Well Location: j fL IL
F—. tL ft.
( lacr7ity/ w Name Facility 09(if applicable) n- R'
J ", �i�. . }e Jr, It. tL
Physical Address,City,and Zip It. ft.
County NJ Parcel Identification No.MN)
5b•Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Wilong is sufficient) 1 22.Cert tion:
N W
6.Is(are)the well(s) Permanent or Temporary Si certified well Contractor: Daze
By fining tlusJorm /hereby cerd/y;that the well(sJ was(were)constivei in accordance
7.Is this a repair to an existing well: Q Yes or No with 15A NCAC WC AIM or 15A NCAC 02C A2D0 Well Construetion Standards and drat a
lfft is a repair,Bll out known well construction irdommtion and explain the nature Of copy of this record has been provided to the trll owner.
repair underM remarb seetion or on ft back of this form 23.Site diagram or additional well details:
8•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 fi is needed. Indicate TOTAL NUMBER of wells baron details. You may also attach additional pages if necessary.
drilled: C SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: f S, (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Formultiple wells listall depdrs itdifferent(example-3@200'and 2@lm construction to the following_
10.Static water level below top of casing: �o (ft.) Division of Water Resources,Information Processing Unit,
If waterlewlisabumcasiag,um•'+" 1617 Mail Service'Center,Rafeigh,NC 27699-1617
11.Borehole diameter:�� (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
jJ /� above,also submit one copy of.this form within 30 days of completion of well
i2 Well construction method: f /r :✓i CO�11��to�fo0o��
(i.e.anger,rotary,able,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: f 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 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: - Amount: / completion of well construction to the county health department of the county
where constructed. �