HomeMy WebLinkAboutGW1-2022-06473_Well Construction - GW1_20220706 Print Form
WELL CONSTRUCTION RECORD (GW For Inlornal Use Only: —
1.Well Contractor Inftirtnalion:
1Ccll('unuaaorNamc � t_nu�f�—' j(i—� �UFa<,Ittl
r ,]6 ,Z S-rt— -�'�- ft.
— — ft. ft. — ——
N('q/ell(17, rnclurCcrlitira wn Numbrr
I5.Otl'(�F;It(Ati1Ni'i(1'or mnitf-wised Wells)OR LINER fit pficable)— —
�_�(ft C�.G�Er • a1 rRt)1tiii mnMr,'I'rck rtncr vr;.vs n _
'- Jt ft. f IY. in.
ongcmy Namc _ .—.._
C'
IG.INNF;12(:A GSIN OR TIU1 9cuthermal claced-loop
2.Well Construction Permit#: 1 JL r^ �i+ ro t,r Gk goons ro n_
l.ie7 ull op/rlir:nhlr,rrll,un.rU-uctiun prru,ir.r(i.i'. ✓''J(',C'u,utA..Sl✓k'. I br ru ,,rh'.) A. ft.
3.Well Use(check well use): —_-.._._-----
VL'aterSupply We is _ 17.SCRI3FN ` -'--
t'uuai '1'U UI�M11 F"1'IiR 31.O'rsIz.r. Tl11CKYF:SS ?lL1'fF:I2LU
DMunirip:dll ublic fi.
Cicolhernrrll(Ilcating(:'poling Supply) r3IResidential Waler Supply(single) -- ----
ti•
hulusn'iallComntercial DlRe'itlenlial Winer Supply(shared) --_.__.
Irrigation i�ROM 1'O -- Ag A'fr•:HL\I. —F:pll'IAC1?h1 F:N"I 11 t•:TNf rD K—A�101:'`'1
• Non-VV'arer Supply Well: ft, ft. .._._
fv9onitoring __— — �Rerovcrs b• ft. _—."--t
Injection Well:
—.._.._._....... .__..._.._..._.—...... --
A,uiter Rcch:n.,e fr. ft.
t E3Graundw:ucr Rcntcdiation
A,auilei'Storage and Recovery 19.SAND/GRAVE'L PACK(If a ilicable)
�iSalinity Barrier ------ _-. ---- _.-._.._._._.-._.__..._....._.
hHt)\1 fY) 11ATISRLU. ...—.— P:11 t'l.nePM t?N-1'kI t:'t•I101)
A,.luif'er'1 est DStorlinvater Drainage tr. I't.
Li;xperimc'ntal'rechnoltl y" DSubsidence Control - fi, tt• -- - - -----_-_ __
(,,eothern)al(Clostxl LunPl barer 2U�DRILLI 'G LOG attach adtlitional sheets If mescal --�-- -
G(utltrtmal(Ilcating/Coolinp.Rchnrltl �0IIIer-(cxplain under'121 Remarksi -- --- of u.Hir rinn(crdnr�har,tru._ura/rocl ry•pc_rvun a'ur.etc.) _
ft.
--- -y - Jr'>;_ui,.
4.Date Well(s)Cornpl
r4 It!;fr 13'r o. ., ark +a f f a'
Sa.Ni4,11 Location:
ft.
s_�C c
/E"o,^A,re r 7(f C ft. ft.
tt
T —.._._
h:rcdilyrUa'nn'N:totc Iihhri l�f a1ti1,hcal,tct ft.
, l
s
1'hyrlc d aI/ '64 lddnrea+...r4_<ily1:�md
('u.Q'1> Y.VarcclldcnWicationNo.IP --
IN1 <M C:`e+h �l7"t(�Q1,bGrvt%'�:o� �,��,it ��f•� �
51).Latitude and longitude in degrees/ntinuteslseconds or decimal degrees:
--
Id,cell ficid.one ial lone i�au(lieicnl I { —.-....._ .._.. �' —..•—__.._._..._. r.
' _'• .J� +r / 22.Certification:
6.Is(me)the well(q)
0Pernianent or 9 Temporary lnauue r l(,.wficd l\cJI(nntiacin Doll: v -
... - Zfi•„l;nu, du,j...... (hrrrh, rrrlih'thot lbe uvv!1 J wa., (n„r'1 nn.,u•n,led to ur•,ua,rre
7.Is Ilus a repair to an existing well Dyes or No i h Is I s< t( 01(*j,N)t),,, 15.1"'V IC 02C 6dnn Wc/l t'„rnn,n:nor,Stu,:d.nd„r„ri;Am r
11)Gis i,a.,lau'".fill ow Aunnn ay.11 rnnd)vu'(i,»)u,ln,'uumnn un l,•.,ylln/u l6r mall,r rrl Iin. t ryrt nl du. rrrord Ian hrru prn,•rdcrl Io tlrr a.r1!u,rgr•r,
r<•pni,wider'r2/rrn,urh.,:,,ti,a or o,r dm 4 ,/this Ilan,
23.Site diagram or additional well de(ails:
X.For Geoprohe/DI'T or Closed-Loop Geothermal VV ells having the saltic Vou Inav use the back ol'this page to provide addilii)nal well site details or well
conxnucuun.only I GW-1 is needed. Indicate 1'O I'AI N1!NIBH; ol'wrlls consinlction details. You may also attach additional pulses il'accessary.
dri IlCti:
SUBMITTAL INSTRUCTIONS
9.Total sell depth below land stet act 60
--(ft•) 24a. For All Wells: Submitthis li d
irnl within to ay. )t'completionl u wcl!
construction to the lid lowing: i
10.Static water leNel below top oreming: 2 S (rt.) Ui\'ision of VYa1er Resourt:I s,Information Processing;Unit.
11❑'o„rr l,•vrl i.c rrlvnr rtt,in!•.u.cr'.;.. '---�._.
/ 1617 Mail Service Ccnl(lr,Raleigh.NC 27699-lbl7
11.Borehole diameter:
241). For Injection Wells: In addition to scildiog,the 161-111 to the address in 24,.
above'also subntil one Copy of this limn within 30,lays of c,;mpletion of wclj
12.VR'e1I construction method: e?✓+�/ L
construction to the following:
(i.c.auwa•r.rnorv,cable.direct pub,cic.t
--- - Division of Witter Resources,Ulu iler•gr•ound Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC_'27699-1636
3a.1'jcltl(g pnq 'Method of,rest: 24c. For Water Sannly l Inicction'cWtW�lls: in addition to sending the ('envoy to
the addressiesl :shove. ❑ko submit zinc copy of this I'onn within 30 days of
131).Disinfection type: Amount:, cong,lction of well Constuction Io the counl IHl:dlh (ICp:urntcnl (It-the count,-
—• svhctc ronstructcti.
harm(ill-I North('nrninsi L?,yeu'nucni.0 r.o,❑.,nmcnl.il I h;dlu,-I)i,r•lun„I\\'alcr ke'om,,.,.,