GW1-2022-01673_Well Construction - GW1_20220128

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
�r)tr S�t�c{c rso ✓� 14.WATER ZONES
Well ConhtraccttorName FROM TO DESCRIPTION
, / �1�_/t -5 �v f L
ft '1
NC Well Contractor Certification
5 ft.
ification Number 15.OUTER CASING for multi-cased wells OR LINER if s licable
�L1SB�L3 y,f��l ll''.' FROM TO DIAMETER THICKNESS MATERIAL
t..VV OT ft 5 ft in. % e
Company Name
36Z ��r Z 16.INNER CASING OR INCTUB (geothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits f.e.UIC,County,State,Variance,etc.) ft ft 1°
3.Well Use(check well use): ft- fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural � clpal/Public S3 it. 1>3 ft in. Aso C
Geothermal(Heating/Cooling Supply) ._- Residential Water Supply(single) ft ft in.
IndustriaUCommercial Residential Water Supply(shared)
8.GROUT
_-Irri ation FROM TO MATERW, EMP EMENT METHOD&AMOUNT
Non-Water Supply Well: ft 00 ft (® uix
Monitoring 13Recovery ft. ft.
Injection Well: ft. ft
Aquifer Recharge E Groundwater Remediation
Aquifer Storage and Recovery 19.'SAN.D/GRAVELYACK`d a
A licable
qu g ry [ Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) I
FROM TO DESCRIPTION color,hardaM solUrock n size etc
ft. 0 ft C 4, -4,W ®�
4.Date Well(s)Completed: y 22 Well ID# to % to % v�✓ C SA yew d,/dd' .
5a.Well Location: 22-0 ft ' e 4-1 /�.iro rk ,5Q,nj
JMMber Rohe,0 11&&11d� ' k CA tnM1,%J 3V ft 5 3 f' 61r vy CA
Facility/Owner Name I Facility ID#(if applicable) fL ,3 ft' 60C f,SC S q.-e
V gper- tr.A^e . Par le Lai*-13 % It
Physical�Add�re�ss,City,and Zip n �/y� l ft ft t
ka'�L ' 13 0 b l02M314 21.REMARKS
County Parcel identification No.(PIN)
JAN 2 g
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification• -
3y0 35 • 9208- N g a /5- Oyy W 02 a az
6.Is(are)the wells) _. ermanent or OTemporary Signature of flea-Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or �T6 with ISA NCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a
ffthis is a repair,fill out known well construction information and 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:
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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBNHTTAL INSTRUCTIONS
n i
9.Total well depth below land surface: / (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(200'and 2@I00) construction to the following'
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" /I 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
tQ�,O i�,!_f� /fr_ J above,also submit one copy of;this form within 30 days of completion of well
1 12.Well construction method: A construction to the following:
(i.e.auger,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) Method of test: P'4,A 24c.For Water Supply&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: 4 Amount: �. bZ, completion of well construction Ito' the county health department of the county