GW1-2022-01951_Well Construction - GW1_20220303

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NNTLL CONSTRUCTION RECORD(GW-1) For Ins tar Use Only:
1.WeII CnatractorIaformatioa:
1&waTERzoNFs _ :-
FROM To DESCRIMON
71eE G ^» ft, M
\CW 1sCe� e rC_^tie on\•+tom is OITIERCASIIYG'ferin casedwens)ORF.7NER d hewe
c- DIMIET
- c FROM TO ER Tffir' r_ MTATEKIAL
r .T ;a. � � — -
L .aa `.� 16.INNlER CA51NG0$Tf1SING eothermal Wed3 )
+° FROM TO DSAIMMI TffiCtCIiFSS MATERFAL
2.TYer?Cantu-M iOn Permit.`4 R in,
1.LK all applicable m-11 corsa+scrio.^.p�raits{ie.UIC',Cmmty Stag P'Ma+rp a r-)
ft. �. m.
3.Well Use(chwk-well use):
17.SCREEN.
Water Supply Well: FROM TO DlAMSTER SLOFSIZE T>� MSATERInL
Agticultr i Mnnicipal(Public ft: % in.
Geothermal(HeatinJCooling Supply) Residential Water Supply(single) ft: ft. in
IndusmalCommercial Residential Water Supply{shared} 1&.GROUT _
11Ii?at10a FRONT TO - bIA. EN ICElTEP1TMErHOD&�'KOinvT
Non-Water Supply Well., ® ft. �t Ci
Nlonitorins ORecovcty ft £t.
Injection Nell: R ft.
Aquifer F,-b r9e Groundwater Remediation D.SA"IGRAVEL PACK - 1e
QiAquifer Storage and Recovery OSalinityBarrier FRONT To MATERIAL £y CEMErrraTsiaon
Araif�-Test OStonnwaterDrainage It. ft'
Experimental Technology 13SubsideaceControl ft. :
Geotee gel(C[osedInap) OTrdcer 20.D12ILI1NGLOG attath'addItEoaalshectsifu "
FROM I TO DfiSCR1PriOtS(colo,hssdness.soehotl• 4- SIMOM)
lGw---e=-1 aleating/Cooling Retum.) Other(explain—der#21 Remadrs) ft + ft Cl >
4.Date Well(s)CompletedA well IDR 0 W)D:71[7� ( M C r
52.Well Locgdon: •a ft. `�" � � J
�•` y £t �
Tt. fL
ra_itiy;t] '�time Facilityg)#(ifapplicable)
% fk ,
& ft.
Paysir_" Ch,;and Zip
&3 q9-U,53 zl.REn REMARKS
5i
Pa=1IdentifreationNo.(PIN)
So.Latitude and longitude in degreesiminutestseconds or decimal degrees:
.. -C1C.^.y�i='--g is 5.tmcient) 22.Certrflcatiom
N W .2 M
c Is(are)thewe0{s} Permanent or Temporary
Si rate ofCerii&ed Well Contractor Date
B!'sigrsing this form,I tn3eliy certify rhnt the tive(1(s)Sias(rcere)constructed in accordance
T, rr is<<o_to ar cfi ne well MYes or No th 134 VXAC 02C.0100 or 15AKCr1C 02C.O200 23re11 Construction Standards and th¢t¢
1f1 i it:r u s�=�.s- +> c.atr: rian irrfarmation erptvin tTie n¢t¢re of the spy ofth&reeard t:as been oravided to the well arvner.
ren XL,r er=,;==; aoraa Zre back afthisform. 23.Site diagramoradrlitionatwelldetails:
8.Far Genprabal3 orCtased-Lropenthermal iTJells having the sa7ae You may use the back of this page to provide additional well site details or well
construction,anh 1 GAF 1 is needed. Indicate TOTAL 3�r[AtdBER of wells
constriction details.You may also attach additional pages ifnetssary
drilled: SUBMIITALINSTRUMONS
9-Total wen depth below land surfacer A) 24a. For AlI Wells: Submit this fame within 30 days of completion of weL
For m,ddpte ue11s Cast dl nets t=ll3��L'i00'and?a()100) construction to the following'
10.Static water level below toll of casing: "Y� + (ft} Division of Water Resources,Information Processing Lint,
if ureter Iem,is ab-a•e C=,,rg Use`=" 1617 I-Vbi1 Service Center,Raleigh,NC 27649 1fi17
n.Borehole diameter. Cam) 24b,For Iniection Wells In addition to sending the foal to the address in 24a
j above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: `� r construction to the following:
auger,romry,o_ble,dsreat o+_h a-'1
' Division of Water Resources,UDdergrouad Injection Control Program,
FOR WATER SUPPLYWELLS MMY 1636 Malt Service Center,Raleigh,NC 276991663
I3a.Yield{gpm} Vfethod of test; 24e For 4irater Sa>sDly&Inflection 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 1 e 3nmamat` completion of well construction to the county health department of the county
where constructed_
Onality-Division o£Water Resources Revised 2-22 2016