GW1-2022-07253_Well Construction - GW1_20220805

1 .
WELL CONSTRUCTION RECORD l• 1
This form can be used for single or multiple welts "r
1.Well Contractor Information:
lA.WATER'ZOlVE5
gyp, I TO DESCRtPTtO\ �
Wall Contractor Name ft.
�• ft.
C7t1 ft. )
C tVcll Contractor Cenifteation-NumberIs.—OUTER CAMNG for mists-eased weft R LINER:f a
F7tOM TO DtADdETER r THIGLtit�S MATFR LIL
! ft.
Company NamettRNER CASIPIG OR d+arinal closed-!m
FROM TD DIAM TER THtCFthFSS MATERIAL i
2.Well Construction Permit M S I ft.
kmi all appkcahle i,ell cnastrurtinn permits fix.f ounq•,Starr.I'ariaaea.on.) ft.
R. in. �
3.Well Ilse(check well use): 17•SCRggN
{{fates Supply Well: FROM TO DIAMETER -SLOTSt2E THICKNESS MATERIAL
;'
OAgricultural OMunicipal/Public
in.
❑Geothermal(iieatingtCooling Supply) 0Residenital Water Supply(single)
ft. ft.
_rindustrialiCommercial 0Residential Water Supply(shared) I&GROVI
[1tOM TO MATERIAL Ea1PLACEM&1TMETHOD&AMOC'\T
Clrngatwn it. CJt� . ylX
1 Non-Water Supply Well:
ft. ft.
i O'ulonitonng ORecovery
Injection Well: ft. iL I
CAquifer Recharge -Groundwater Rcmediatton 19..SAIVDIGRAVEL.paCi: if irshk
CAgtuter Storage and Recovery OSalinity Barrier FROM ft To �' MATERIAL EJSPI►CEMENT)IECHOD
0AquiterTest uStormvaterDrainase fs. Ft. '
EExperkiiental Technology OSubsidence Control
28.DRILLING LOG attach addidatml skcets if necessary
OGeothermai(Closed Loop) OTraeer 120M TO OFSCRIF170\tmlar.bud=&seiltrodt e•ninssu.ercl
COcotherntal(Hcattnz Cooitng Return) GOther(explain under 921 Remarks) fa fr
ft. fL
4.Date Welt(s)Completed; fs. ft.
5.Well Location: ft.
t r
ft: ft i r 202Z
I�u1it).4wne:�amr Facility 1D-(+f applicable) ft. ft. j
�_l LXtiT1JLt�ULI Dav e 1 ft. ft. Dl�d�l30C3
N sicat Address.(•n),and bi L 1
N^' 21•REMARKS
D JIM ~ �'
C'ou,tt,. Parcel ldeiuitieationNo(PIT)
5b.Latitude and Longitude is degrees/minutes/seconds or decimal degrees: 22.Certification:
(+f well field,one lattong rs safFieuenf)
ZAK
�,� G SiSmitire of Ccnified Weil Contractor �1e
6.is(are)the eetl(s): �Pcrttlaaent or ❑Tetaporaty ('
i!y sit;nnrg thts faun./here eer!!fy!lint the ti tllftr gas Grin/ratslraurd nt it,onvtont c•
x'a!r l9A,NCA('112t .aloft m•ISA NCAf'r)i wan ici.•il C itnsrruetn+a.Vaudartlt and shut o
7.Is this a repair to an existing well: Dyes or /No caps of t/us record hat been pinvided In the hill towner.
//dim t:,er rrparr,hll all/Itarrwa well crnssttwenar mformathin and explain tire name rtf the i.
repurr under::2!rcMarir xeetmn:tar an the hark of this farm.. 23.Site diagram or additional well details:
1 You Wray use the back of this page to provide additionalwell site Jctail,or trill' y
S.Number of wells constructed: construction details You may also attach additional pages if necessary
Far nwhiple alrrnrnr for nar•x•ntc rsnp/rh•v e//s ON/.Y m-A the samr crustraclynn.you can
whadaar farm 1 24.Submittal Instructions:
9.Total well depth below land surface: 3 05 (ft.) 24a. For-Ail Wells; Submit this ftlrnt within 30 days of completion of well
I•},r and9ple n elk lost all dept/4 it ehllerent feromplr•3•^C 2MY 0ttrl?(Cc flrf) construction to the following
10.Static Haiti level below top of casing: �Q (ft,) Division of Water Quality,;information Processing Unit,
1 i,at.-rile a er er.u.+betw.n.,,••• " 1617 ylail Service Center,Raleigh,NC 27699-1617
24b.For injection 11.Borehole diameter: In addition to sending the-form lathe address-:n-2Ju —
1Y - - (in.y
above, also submit a copy of this Corm'within 30 days of compleuaf'- of Will
12.Well construction method: Q� construction to the following.
(+c auger,rowy.cable.direct push,etc.)
Division of Water Quality,Underground injection(:ontro!Program,
13.FOR WATER SVPPLV WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
A F / 24c.For Water Suonly&Geothermal Wells; In addition to sending the(form to
13a.1'icld(bpm) h4etltod of test: the addresses) above, a6v submit one copy of this form within 30 days of
136.Duinfectioatype: Cr/1 f�'!TY1 _ Amount completion of Weil construction to the county health department of the counr\'
where constructed.
Form Gtt•'-t %. onh Carotins Department of Envinnment mid Natural Resoureea-Division of Water Quality Re„se3lai:201:t
f .