GW1-2021-07264_Well Construction - GW1_20211006

tLL JJUIVDI nUU I IUIV t1tuUnU It3vir-11 rotlrre ai Use Unly:
1.W Contractor I or-ati :
14.WATER ZONES
WeII ame FROM TO DESCRIPTION
7 j 6 ti0ti ��\� n n
n n
NC W ConaacturCrfifieationNumber ��\ tpre4,\pn I&OUTER CASING r multi d:veetLS QR LINER liable
C e p\C�C,6J FROM TO DIAMETER THICKN MATERIAL
Company Name ���J ' fL L b tL in.
7 O O � 1 INNER CASINO OR TU81NG rmalclosed-too
2.Well Construction Perm it# l/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable we//corwIlchon permits�.e.U/C,Courtly,S&M Variance,M) n n In.
3.Well Use(check well use): n n in.
Water Supply Well: FROM ITSCREEN 0 DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural cipal/Public ft. ft. in.
Geothermal(Heatrng/Coolmg Supply) O deffial Water Supply(ogle) It. it in.
_ lndustrial/Commercial Residential Water Supply(shared) 1&GROUT
.o. FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d n O`f n LRto O m Our
Monitoring [3Recovery n n 57A Vjiltz G �s T#-,
Injection Well: n n
quifer Recharge [3Groundwater Remediation
19_SANDfG RAVE L.PACK ffa licabte -
uifer Storage and Recovery [jSalinityBarrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test oStormwater Drainage n It.
Experimental Technology Subsidence Control fL tL
Geothermal(Closed loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 0Other(explain under 421 Remarks) FROM I TO DESCRIPTION color,hardness,soillrut IyK grain sic etc.
Q� 0 n n 63
4.Date Well(s)Completed:��U�� Well 10# �5 I q D n' A 7 ko c K
5a.Well Location: 4 n 4;.-2— n it
Cn 9S fL y
Facility/Owner jNam ,( Facility M9(ifapplicable) ft" It.
n n
Physical Address,(Sty,and Zip
n n
21.REMARKS
DIC4
Co.ty Parcel Identification No(PIN)
5b.Latitude and longitude in degress(minutes/seconds or decimal degrees:
(dwell field,one lattlong is sufficient) 22.Certification:
N W � U�
6.Is(are)the well(s)EIPermanent or Temporary Sipatureof ' ed Well Contractor mate
� By signin L'ris tutu,/hereby certify,that the ov/1(s)nos(were)constructed m accordance
7.Is this a repair to an existing well: Oyes or E. No widrl5ANCACD2CAf00or15ANCACO2CAM Well CownvebonSZLWardsandfhata
ff this is a repair,fill out kiwmm well con Muction information and explain the nature of Me copy of tins record has been provided to lire well owner.
repairunder#21 remarbseWonoranthebacIrofmisform. 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 Gr-1 is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 95 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For muAlp/e wells fist all depths if different(example-3@200-and 2@I001 construction to the fallowing:
10.Static water level below top of casing: ��� (ft.) Division of Water Resources,Information Processing Unit,
ffwater level is above casing,use^+ 1617 Mail Service,Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Iniection 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 Q Li t 1 t D' construction to the following:
(i.e.augrd,rotary,cable,direct push,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) 1 Q- Method of test: 24c. For Water Suooly & Iniection 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.