GW1-2022-01459_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only
1.WeQ ContMCtDr Information:
50 4', ( (a4z., 14.WATER ZONBS
Well Contractor Name ` FROM To DESCRWnON
ft. ft
NC Well Contractor Cucnoecoa Nnmles
, l r
W a 6- �il FROM To D1AblSTSR THICRNa8t3 MAT>3xrAL
fr. s. i In.
CompanyNama
1 INNSRCAIDIGORT[1B1NG dosed-I
2.Well Construction Permit#: FROM To I DlAbtg-= I TmrxtNRss IMATSRu1.
List all applicable wail constturrionpv7tdAr(lie.UIC,County,State,Variance,etc.) it. ft
3.Well Use(check well use):
Water Snpply Well: 19'SCREBN
Agricultural icipal/Public poM fr. To D In. starers Tt3aw
Geothermal(Heating/Cooling Supply) dential Water Supply(single)
Industrial/Commardal E)Residential Water Supply(shared) i&GROUT
Irriotation FROM To MATMUL I 0M ACi39MAI r MOD&AMOUNT
Non-Water Supply Well: D G tt ©lirr
Monitoring & Ei; G A S
re on Well:
ft ft sN
Aquifer Recharge DGroundwaterRemediation 19 ! VEL CR . . lleabk
e—
Aquifer Storage and Recovery Salinity Barricr FROM TO MATERUL ENlPLACBdl88rr D
Aquifer Tat OStomrwater Drainage R-
_ Experimental Toclwology DSubsidtmce Control & &
Geothermal(Closed Loop) Tracer 20.D G LOG attach additional dptts E
Geothermal Coolin Return Other(explain under#21 Remarks FROM To DascR>pr10N mar ana/roek
4.Date wen(s)Completed:12 1-5 -2/ Well iw ft
Se.WeR Location: LL ft. ft.
ft. ft.
Facility/OwnerN�Name Facility M#(if applicable) fL M
�rGGOSSIng t i
Physical Address. •ty,and tip R' S.
l�L+� 2Z5 2TZI 21.REKARas
County Parcel Identification No.RN � '+ i✓i
Sb.Latitude and longitude In degrees/mtnates/seconds or decimal degrees: ''� AC
(lf well field,one lat/long is sufficient) 22. • ca on:
<36013"53. hQ-2 l N Ze0 ?Z4. ,96,�Rr
-A 1111-911114ID;,7.
/Z• /S� 2 I
6.Is(are)the well(s)Qe1'manent or Temporary i of wen or Date
rep8lr By signing this furor,I hereby awi&dart the arA(s)war(were)exulruaed in auvrdi me
7.IB tbis a to an well: Yes or o with 15ANCAC 02C A100 or 15ANCAC 02C.02W Well Construction Standards and that a
If this is a repair,fill out lawm wet!aonanuction information and explain the nature of the ropy of this record has been provided to the well mvner.
repair under#21 renwkssecdon oron the back of dusfomL 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 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details—You may also attach additional pages if necessary.
drifted: SUBMITTAL INSTRIICTIONS
9.Total well depth below Iand surface: 00 24a.For All Wells: Submit this fbtm within 30 days of completion of well
For multiple wells list all depths fdf6erent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 210 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above oaring,we";^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (In.) 24b.For Julaction Wells: In addition to sending the form to the address in 24a
12.Well construction method. kabove,also submit one copy of this form within 30 days of completion of well
Lf construction to the following:
(Le sage;rotary,cable.directpask eta.)
Division of Water Resources,Underground bdection Control Program,
FOR WATER SUPPLY WELLS ONLY: n f 1636 Malt Set vicc Center,Raleigh,NC Z'76MI636
13a.Yield(gpm) _Method of test: �"�1 Q(A2 n �f� 24A For Water Supply&Infection Wells: In addition to sending die form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:-,1� Amonat: 9Du•-jets completion of well construction to the county health depamnent of the county
where constructed.
Form OW-1 Norm Ca vUha Depamuent ofEwArommintal Quality-Dmudon of Water it ea 1tev sea 2-22 2016