GW1-2021-00442_Well Construction - GW1_20211206

WELL CONSTRUCTION RECORD '
This form can be used for sin-ale or multiple wells
1.Wellf Cuntrac}toor Information-
( hij�� n
,S itA./f t3LYQC�� 16.WATERZ(lidiFS
FROM TO DESCRIPTION.
Well Contractor Name
22 i
ft. I
C'WeilContt2ctorCcrtificationNumbtr ]S.OUTERCASING formuW-eased-eft OR LINER :fa lc
FROM TO DAMETER THICKNESS MATERIAL ')'
! I 1 0 fr. f:. CD fq �` V
Compam Name Zt7.
NER CNGORTi1i ft. TO ft. DJAMETER THICKNESS MATERIAL 1
2.�i ell Construction Permit#: P a in. I
I.r>I all appk'whie Bell ca»xlruc'lian peanilx fi.e.(bunn.,Stare,l'arlonce.ere./ ft. ft. in.3.Well Use(check well use): REEN11'ater Supply Wd1: TO DIAMETER SLOTSi2E THICKNESS MATERIAL
ft. ft.
(Agricultural cMunicipa)/Pubiic
/ ft. ft.
❑Geothermal(Heating/Cooling Supply) Vc.denttal Water Supply(single)
MIndustrialiCommerclal (Residential Water Supply(shared) FROM
i ROM TO !1ATERIAL E?IPLACEME\TtriETHOD&AalOC:�T
I Oirrtaatiun ft. ;to 'ft. +x
Nou-WaterSnpph•Well: rt te.
0hiloriitoring CRecovery
i Injection Well: fI. ft. t
CAqutfer Recharge .^,Groundwater Remediatlon 19.SAND/GRAVEL PACK ifa lkable
F MATERIAL
CAgwfer Storage and Reeoven' OSaliniN 8arrtcr ROM To £�tYIAC'EMENT�tl'1'iIOD
ft. ft.
I OAquifcr•1'cst uStontnvater Wamase ft. ft.
❑Experimental Technology OSubsidence Control 20.DRILLING LOG attach additional sheets if necessary
20cotherm4i(Closed Loup) MTraeer iaom TO DESCRIP12ON' enter,hasdtuss.saillroek N e.-rain sire.etc.
CGcothcrmai(Hcaun=Coolme Return) DOther(ea tam under 421 Remarks) fa ft.
9.Date Well(s)Completed: ft, ft.
S.Well Location: ft* ft.
Gwen girl obre ff. ft. QFC 6 2021
i:eiliq.0%%ne:N:nle isellinlDr(ifapplieable) ft. ft.
�1y �}urveu Loran P.d►. ft. ft
I NMI
Physical Address.Ctl%,Ind ZIP 21.REMARKS
P,u h r�rord :3;)U1D 1'a
C ount.% Parcel identification No(PiN)
Sb.Latitude and Longitude in degrees/minutes/seconds or doeimat degrees: 22•Certification:
pf%well field,unc tit long is suf9efen)
►a�i
� Signature afCcniffed Well Contractor Date
6.is(are)the weli(s): t$Permaoent or OTemporary By signing this ttriu,/herrhy cent(-drat the neat.%,Rite nreny t'»uvirutlrr/nl mcnntumv
/ wills lSA NI'AC'fl2C',OlOU m•/SA NC'AC'02C' 01IRI IP'ei/C'nnvrn,c»aa.6n»r/anl%and Ihul a
7.Is this a repair to an existing Well: Dyes or 540 cart I#this record hax her»pirividrd it;the urll aa•ner.
//ti,ra rn a reparr.h/l tint krtrnv».,•e//crutvrrue IIIi I tnfr,rinaatin and expledoi the aanrre qI Ike 23.
1
repair under;:21'emarkv>•ecltan or at the hack of this forin. Yo Site diagram or additional well details:You may use the bank of this page to provide additional%cell site dutaih or well`
8.Number of weiis constructed: construction details You may Disci uttach addlttonal pages if necessay
I•i,r nutlnple w/ra'm:n ur mut.frntrr.vnpp/t„e//%ONI.S'a uh/hr.came ca+arlratdart.}r+o call
,uhnw uni•Jarnr 22 24.5ubmittal Instructions:
9.Total well depth below land surface: =7d� (ft.) 24a. For All Wells: Submit this farm within 30 days of completion of%tell
1-tor audN/*!e t„•ltrhvl ill di plb..J/dd/rren!fe.maiph•3•fa200'010 2
i lurr'I construction to the fo))OWing
iQ.Stacie tracer level below top of casing: w (ft.) Division of Water Quality,Information Processing Unit,
I nutstic I a er level
el be.u.,.••• 1617 Mail Service Center,Raleigh,NC 27699.1617
W
21.Borehole diameter:. I t�(in.) 24b. For Injeetion Yells: In addition to sending the i'orm to the address in 2Ja above, also submit a copy of thts form within 30 days of cumolction of%veil
12.Well construction method: 9NA far Ll construction to the following.
(I a au�cr,rolesry.cable,d3rc4i push,etc.) I Division of Water Quality,Underground Injection(:ontrol Program,
i3.FOR 1�'ATER S[fPPLI'WELLS Oi�L�': 1636 Mail Service Center,Raleigh,NC 27699-1636
i 24c.For Water Sunnly&Geothermal AO: In addition to sending the forin it,
13a.Yield(gpm) 1 5 Method of test: I t the address(es) above, also submit one copy of this form within 30 days of
1 13b.Disinfection type: ��1ki31'i!'1{'_ Amount: O� completion of weii construction to the county health department of the county
1 _ where constructed.
Form G -I Nanh Carolina Department of Environment and Natant!Resources-Di%•tsion of Water Quality ke%ised late 2011