GW1-2022-03027_Well Construction - GW1_20220228

} V11 t L L G U IV O 1 t9 U U I I U N M t U U tt U (t7 VV-11 For internal Use Only:
'1.Well Contractor Information:
14.WATER ZONES
well Contractor ame FROM TO DESCRIPTION
G-q It ft.ft. ° It.
NC Weft ContiactorCertificationNumber 15.OUTER CASING farmulti-casedwells)::ORLINER If T;a ieahte
FROM TO DIAMETER THICKNESS MATERAL I
fl fL Sf fL L, In. Sal Z
Company Name 1&INNER CASING OR-TUBiNG rmalctosed-1
2.Well Construction Permit# FROM TO DIAMETER THICKNESS MATERIAL
List all applicable wafl emrstrue ion permits(Ln U/C,Comfy,Stat4 Variance,M) n n in.
3.Well Use(check well use): ft. n in.
( Well: 17.SCREEN
Water Supply y FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [3MunicipwU lic n n in.
Geothermal(Heating/CDOling Supply) Wesidemial Water Supply(single) n It. in.
Industrial/Commercial Residential Water Supply(shwed) I&GROUT
71irrigation
FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d fL D`E' It- P) =9Z 6bt-T ZI.-I
3- Monitoring
c Injection [3�v� ')3�OLSft ft 57AAD I G wr 'raJ
9aifer Recharge [3Gmtmdwates Remediation / ft. / n t'ldlal3.,, UL�
1&SAND/GRAVEL ACK if liiable
Aquifer Storage and Recovery DSalinityBarrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage n tt
Experimental Technology 13Subsidence Control n n
Geothermal(Closed Loop) Tracer 21LDRILLINGLOG attwh additional sheetsUnecessary)
Geothermal(Heating/Cooling Return) rJOther(explainunder#21Remarks) FROM I TO DESCRIPTION color,h2rdnmsWVruckVK grainsize,elc.
It IL
4.Date Well(s)Completed: 2--/ Weil ID# R- n-
5a.Well Location: n n
bhU D e- It. n
Fae ty/OKmer Name Facility M#(if applicable) n n
90 Aril rnoyr- s1E. PUd'ant Ak Z771s ft. n
Physical Address,City,and rp n n
Q)uGham f �03GQ 21.REMARKS
UrA
Comity Parcel Idendficitif on No.WIN) pf.,�,.".y�
5b.Latitude and longitude in degrees/minutes(seconds or decimal degrees:
(ifweu field,one Iat/long is sufficient) 22-Certification:
N W
s I&&If Aka&2l.2•l��
6-is(are)the well(s)�ermanerlt or ]Temporary Signature of edwellContractor Date
By signing this form I hereby cerafy lliat the walls)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or M4010, wiffi15ANCACO2C.0100or15ANCACO2C.0M Well CafaftuctiouS&Wards and thata
ffffia is a repair h7l out Imam welt winvuerion information and explain the nature of the copy offfifs record has been provided to the well owner.
repair mder01 remarks section or on 0m back ofthts faun
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 weU
construction,only I GW-1 is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: "115" (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells fist all dep0a ffdifferent(example-3@200'mrd 1 tQr 100� construction to the following:
10.Static water level below top of casing: -- OIL) Division of Water Resources,information Processing Unit,
ff motor level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
above.also submit one copy of this form within 30 days of completion of well
12.Weil construction method: 1)HD construction to the following-
(Le-anger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: AA 1636 Mail Service Center,Raleigh,NG 27699-1636
l 13a.Yield(gpm) to 0411- Method of test: 24c- For Water Supply & injection Wells: In addition to sending the form to
5 / the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ` ' �`•� Amount: completion of well construction to the county health department of the county
where constructed.