GW1-2022-06747_Well Construction - GW1_20220603

1 111117 well
WELL CONSTRUCTION RECORD(GW-1) For Taternel Use Only:
1.Well Contractor Information. /
�/� Lu 0 -14.WATERZONIE4
Well ContraetorName FROM I TO DESCRIPTION
CK R. :i- &
WC well C Ce��Mmb= 1 r
R
�/t.,� �" � 7_�-r,'�., '; ii'1•Z FROM To Drann;Tsx I THIccaNssa ns/►TERUc
ft ft. In.
Company Name
16 HOMER CASING OR TUBING dosed400pl
2.Wen Construction Permia: FROM I To I MAMSIBR I 1111QCNIRM I MATRWAL
List all applicable well cownctloa pwnits(le.M,Cautery.State,Vadanes,etc.) ft. P_ 1n.
3.Well Use(check wall use): ". ft. Itt.
Water Sapgly Well: 17:SCREEN -
FROM TO MANXTER, Shirr suz TSRiAL
Agricultural icipat/Public O ft. EL in.
Geothermal(Heating/Cooling Supply) dential Water Supply(single)
t3. R. in.
Industrial/Commercial E)Residential Water Supply(shared) I&tRtOUT
IftTiggon FROM TO MATIOMM, Es2L CB HNTMRTMM :AMOUNT
Non-Water Supply Well:
MonitorinDRecavery fw ft. E
Inflection wen:
ft. ft
_. Aquifer Reohatge DGroundwater RemediatioaD. VM l?ACK fifeemUmble)
Aquiibr Storage and Recovery 03alinity Barrier PROM TO MATERIAL OD
Aquifer Test OStomtwaW Drainage ft. ft
ExperimcoW Technology OSubsidence Control ft. M
Geothermal(Closed Loop) Tracer 20.DRUJMG LOG attach additional sheds if vacessaM
FROM TO D&SCR1PTtON mar,burin sdVrvek etc
Geothermal eatin Coolin Retum Other(explain under 921 Remadcs 0 � I ft- � �i��:A
4.Date WeWs)Completed: -?3`-O Wen M 7 ft- -tt'
.oaf./.Well Location: ft. -�f+-
.*..
Facility/Owner Name Facility M#(if applicable) ft. ft ..- : , t_
ft ft. JON U 3 zo
Physical address.ft andZip
kf
County Parcel Identificatim No.(PIN)
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one tat/long is sufficient) pt 22.Certification:
6.Is(are)the well(s) Permanent or E3TempOrafy Signanue of Cettified ell r Date
4 signing this form.I hereby cgrrVy drat the weil(s)tvas(were)aonmcfed In awardance
7.Is this a repair to an existing well: OYes or Wo with 1SANCAC 02C.0100 or 11ANCAC 02C.02W IVeH Consnucdon Standards and that a
If this is a repair.fill out known well construction information and aTtaln the nature ofthe copy of this nowdhas been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additioasl 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 ofwalls construction details..You may also attach additional pages Unecessary.
drilled: ;IUMM[TTAL INSTItIICTION3
9.Total well depth below land surface: 4 fn i0 (R.) 24a.For AB Wells: Submit this form within 30 days of completion of well
Formultiple wells list all depths ifd ffermt(emmple-3@2001and 2Q1005
construction to the following:
10.Static water level below top of analogs ?_r,_ (ft) Division of Water Resources,Information Pcocess;ng Unit,
If water level is above casing,use'•+" 1617 Mail Service Center,Raleigh,NC 27*9.1617
11.Borehole diatebea 69(�� (in.) 24b.For infection Wglls: 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.Well construction method: t--h :a v1 constnuchion to the following
(Le.auger;meaty,cabl%dinectpask etc.)
Division of Water Resources,Underground Ielection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Strvke Center,Ralelgh,NC 27699.1636
13a.Yield(gpn* Method of test N O A)^ 20#'- 24c.FOr Water Sam&&Ind CHM Welts: In addition to sending the form to
the addres(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: '� �y ` Amount: "Y t,tytLt 5 completion of well construction to the county health department of the county
where constructed.
FormGW-1 Worth C11101 aDepatmtentofErtvironenentalQuality-DivisionofWaterResomm Revised2-222016