GW1-2021-00564_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(QW-1) For Internal Use Only:
1.Well Contractor Information:
Yfr 14.WATER ZONES I
Well Can tractor Name PROM TO DESCIUMON
ft. &
ft. ft. rr K
NO wen Contracimce,twim ionNaaimw 'I5.OUTER rmWtl=WseA we oRLIIOR. uceate
1'^ —r �- _ 1 1 FROM TO DIAMETER TffiCKNE38 MA773RIAI.
1 "�/ �-+ 1/V ' �.
Company Name
I&RMO1sRCASINGORTUBING thernaidosed-loo
2.Well Construction Permit#: FROM I To DUMEM TMCKNESS MATERIAL
Fist all applicable well consimcdon pem is(Le.UIC,Coring,State,variance,ele.) ft. & in
3.Well Use(check well use):
Water Supply well: .17.SCREEN
Agricultural rcrpallPurblic t) n. ft.
PROM , TO D n. srvrsrzs rinc>;antss MwTRrrr.r-
Geothermal(Heating/Cooling Supply) dential Water Supply(single) ft. tY. in.
Industrial/Commercial E)Residendal Water Supply(shared) 18.GROUT
Ini 'on FROM TO MATERIAL EhMACE UM-METHOD&AMOUW
Non-Water Supply Well: ft. rG
Monitoring - Recovery ti. ft. rt l b©©
Injection Well: , .
Aquifer Recharge OGroandwater Remediation
Aquifer Star aril RecoverySali $cycler 19.SAND/ VRL PACK f licaMe .
�Y FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test rlStormwater Drainage ft. %
Experimental Tcohmology 13Substdcuce Control IL m
Geothermal(Closed Loop) OTracer 2(LDRHMG'LOG.(agwhadditiovAAeebEupmmxA
10cothermal.aLmdwWCooling Return Other(explain undcr#21 Remadss FROM I TO DESCREMON mine a4vmdc
IL IL ©vim
4.Date Well(s)Completed:..L. 2 welt IDS`4 719 27 u.
4 le
� s
Facility/Owner Name Facility ID#(if applicable) % DEC 2
1-727 do.-titam, AL % It.
Physical Address.City,and Zip
25 92AA 21.REAIARBB ii l.iiSi
r
County Pineal Identification No.(PM �
I
5b.Latitude and Iongitude in degrees/minutes/seconds or dedmai degrees: I
(if well fiel(l,one Wong is sufficient) 22.Ce ' ea' n:
�6°�9 ���•/oases'IN1d e SD' �3 'Sg�f�,=w
6.Is(are)the wells) Permanent or Temporary cemsad well Daze
BY signing this form.I hereby cm&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or (3116 with 15ANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Stan&u*and that a
I/this is a repair,JU out Amown well consimcdon Informarionand explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells construction details..You may also attach additional pages if necessary.
drilled: STHN RIT'rAL. INC
9.Total well depth below land surface: :Zv/9 (R'.) 242.For All Welly. Submit this form within 30 days of completion of well
For multiple wells list all depths ijd$erent(example-3Q200'mid 2®I005 construction to the following:
id.Static water level below top of casing: Z Divialon of Water Resources,Information Processing Unit,
Ifwater 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 farm to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12,Well eonsMnetion method: construction to the following
(Le-auger,votary,cable,direct posh,etc.)
Division of Water Resources,Underground Weetlon C6ntrol Psogamm,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Swvloe Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I C_e.r _Method of test .For_Water SrmDly&itnieetion Wells: In addition to sending the form to
e address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: A4 (K Amount: 2-19 c,. u-, iA completion of well construction to the county health department of the county
where constructed.
Form Gw-1 North CarolmM-parmtent ofillmninmental Quality-Division ofwaterResaurees Revised 2-22 2016