GW1-2022-05541_Well Construction - GW1_20220603

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only
1.WeH Contractor Information:
.. f'l x 14.WATER ZONM
Nell ConlractorName I FROM TO D3SC,REM N
r?u - 00,1 ft. Z C ft. tC 4AF)
ft. Et.
xc wet cone c -• _
�+ - Zp��i� G FROM TO rill DIA[iiBR (2CNB38 MA
Company Name ft. ft' �' •2d
16.IlVN$R Cd►SINi}ORTUDIMNG dassd�
2.Well Construction Permit: FRot�l TO DIANWM jMCKN ss MATSBIAL
List all applicable well construction pamdrs(i.e.UIC,Cown)4 Sate,Variance,elc j Fft. fL in.
3.Well Use(check well use): - ft, in.
Water Supply Well: 17.9ipm —_
Agricultural E)Municipal/Publio OMft. R ia. SL�f MATRArdt
O
Oeothermal(13eatinglCooling Supply) DResidential Water Supply(single) ft. lm
IndustrlallCommercial DResidential Water Supply(shared) 19 GROdT
hTi ation FROM TO MATERIAL MEMOD&AM0
Non-Water SttpplpWell: ft. M A �I
J
onitoring ecovery t;;
unn Wen:uiferRadtarge �Grotutdara6erRemediationit.uifer Storage and Recov FMRMnolcry �3aiinityBarricr FxoM To vrn�uifer Test ©5tormwaterDrainagepadmvnW Technology [DSubsideno Control ft. ft.
othermal(ClosedUop) Tracer &G.DRILIdNGLOG attach additionalshcefsEnothf�al eating/Coolin Return Other lain under921 Romulus) FROM To DB iCRIPSIOrY color trenta wilhodc sla etc
4.Date WeU(s)Cowpieted: 3'/� Q 1.�' well im ft. ft.
Sa.Well Location: / f it. ,
(_ IFJy' � ft. ft. r
A�'1_ s; JI.
FaeilitylOwnerName Facility IN(if applicable) ft. ft.
7117 At ,�.. cr.L1. h�t t c�' ft. ft. 1 UN
?bYsical Address.Cim Ord Zip
06.,qt 2I.REMA13$S —
FunlY Petrel Idenfificatioal3o.7M
Sb.Latltude and Iongitude in degrees/minutes/seconds or decimal degrees: t
(if well field,one latnong is sufficient) 22.Certification:
6.Is(am)the well(s)(3Permanent or [nTempotary Signatui0i 60ntiSedWeIl Cadm6tor Date
BY signing thlifnrat,l hereby a2iiFy&at Me wells)ryas(were)con meted eted hi arordmtce
7.1s this a repair to an existing well: E)Yes or [3Np lvith 15ANCAC 02C.0100 or 13ANCAC 02C.0200 Well Constructian Standards and that a
If this is a repalr,fill out known well conmrucdon lnfarmatlon and aplairt the mute of the copy of this record has been pravlded to the well rnvner.
repair under#21 remarks section or on the baa(of this form.
:3.Site diagnini or adtiifiolral well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal'Wells having the some You may Use the back of this page to provide additional well site details or well
construction,only i GW 1 is needed. indicate TOTAL NUbMER of walls const ction detaU&.-Yon may idso attach additional pages if necamary.
drilled: 0M
9-Total well depth below land sueace: ' J 24a.For AD Wells: Subadt this form within 30 d of corn lation of well
For multiple wells Ust all depths if dUuent("maple-3Qo 200'mud 2@100) ( ) construction to the followinw p
10.Static water level below top of casing: (ft.) Division of water Resources,Information Processing Unit,
If water level it above cuing,use"+• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. a, ) 24b.For Infieedol)Weft In addition to sending the form to the address in 24a.
12.Well construction method: 1"11 above,also submit one copy of this form within 30 days of completion of well
(Le.-&M rotary,,able,direct past,ere-) construction to the foIlowing
FOR WATTR SUPPLY WELIn9 ONLY: Division of waterResomves.Underground bdeetlon Control program,
163d Mai!Stxvtce Ceniar,Raleigh,NC 276491b36
Na.Yield(gpm) _ZS Method of tebt Nda>A 4f//++' 24c.For Water SDfmly&I;iectw,_,EWell>, In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfectioa type: Amonn� sue�� S completion of well construction to the county health department of tice county
where constructed.
Form GW-1 North Caunlius DepallmentofEnvironmaoml Quality-Division of WatarRasarutes
Revised2-22-2Oi6