HomeMy WebLinkAboutGW1-2022-07660_Well Construction - GW1_20220818 Print Form
WELL CONSTRUCTION RECORD(GW-1) bur Internal Use Only:
1.Well Contractor Information:
14.WATER 70NES
FROM 'ru DESCRIPTION
Well C'onuaelor Namc
rt.
NC Well Contramir Ccnitiaaion Nurnhei 15.OUTER CASING for multi cased wells)OR LINER f n licahle
f� e- /X FROM I'o ul.tau.Tt.R T TIOCt:Nt." MATFRIAI.
Coniraity Nioto
I 16.INNER CASING OR TUBING eother al closed-Inn
2."'ell Construction Permit#: le I- EPA 1402a r0 Vol I FROM I DIANIVICA Ttttcl xF c slsn:Rtal.
l.ia all nppli.ith(r nx•ll rnn.cuvrnnu perrrri,e N.r.1'l('.('ruuur.Stare, I'iu•innce ru.l ff. ft.
3.Well Use(check well use): ft. ft. in•
Water Supply Well: 17.SCREEN
FROM To pLtMf.TI7R SLOTSIM TIIICKNFSS MATERIAL
Agricultural DMunicirill Public ft. ft. In.
Geothermal Il leating Cooling Supply) OResidential Water Supply Isingle) tt. ft. in. I
Industrial)Comntercial OResidcntial WIntel-Supply(shared) IR.GROUT
irr•ation FROM IO \IATE.RI.u. BMPI.ACta1ENT ME I It Op c.AMOPNt
Non-Water Supply Well: ' ft ft. u.
Monitoring QRccov•r ff. ft. j
Injection Well: P�. LLIL
L n. u.
Aquifer Recharge [:3Grotmdw'atcr Reniediation
t\goiter Storage and Reco, Unii 19.SAND/(RAVEL PACK life licoble
y�Ftla`sf 41RfdT;�f:i fcr FROM u) wA'rF;w:u,- EMMACEMENI vIETHOD
Aquifer Test �\ irnniwater Drainage ft. ff.
E.xperimental Technology Dsubsidence Control ft. ff.
Geothermal(Closed Loop) 13'fracer 20.DRILLING LOG fattach additional sheets If necesst rr
ECocothcrotial(I lentin riCooling Return) Other(explain under+,Z ) Ff rot OFSCRIP'nt�N(raaF.hard-.snu0mck tr e.vain if".erc.�
1 Remarks
4.Date Well(O Compieted:7-P-L Z 11'eII IDN � / �a rr. LL � n. 6 r a i Z,J_5e.
So.W'ell Location: (} ft' ] S tt'
CPC`
¢
FacJity%ft,vncr N;anc Facility I10(if applicahlel ft. !t.
Phrareal AJJres..(hy.,and Zip
rt. rf.
21.REMARKS
��rr JJ
('onnly Parcel Identification No.11'W i vrAr tJ"1fv�/ Ao ek r e, l Ce-__
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: fP r S � ✓iG���"P/Et• e. T r�^^ e a
t,t well field.one lat.long is sufficient) 22.Cc fificalitim � p/� ♦i✓ �'�e �/ P��--�' L�
3s �3)3 N ` for 2-32-
�1jy 7-
6.h(arc)the well(s)OPermanew or Temporary Sien:uurc ol'Cerlilicd Well Cnmracax Umc
Qr siynirrg this%nrnr. l hrrrhr rrrti/v thtu ill.,nv//ar miv At-et-nsirmrlr,l rn-,--dance
7.Is this a repair if)an existing well: Oves or ONo rid:15.4:v(.ac oz(-.Oloi),,,•1.5,1 xCGu'!13(' ll?Ito If.//('nu..nv,vi,nr Srarulard,and dray
11 thn A a n pair•(ill nW knmrrr"ell nun,bmir Iwo inlnr'rnutiarr and r.,plum the mauve nl dr, rnlrr aJ thrr rrrnr'd has h...t/ ided n,Me will--er.
np,rvr under n:1 rrrnark.,rirtinrr„r,nr ill,,lwr4 of Mi.s lure+
23.Site diagram or additional well details:
X.For Geoprobc/1111"F or Closed-Loop Geothermal Wells having the sanle You may use the back of this page to pmvidc additional Weil sue details or well
construe'Iton,,inly 16W.I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drlllcd: _....:....-.._...._.._- SUBMITTAL INSTRUCTIONS
9.T•ntul well depth helow land surface: S'a -(ft J 24a. Vol- All Wells: Submit this Iiirm within 30 days of completion of well
l%rrr nnr!l+plr•a /Ic!rct,dJ;Irpdt,q dUlrmnt(r,tmgrlr-7(ri_17(7',na!?Ly 101r'I
construction to the following:
10.Static water level helots top of casing: _2 s Division of Water Resources,Information Processing Unit.
/r+.„t,• l,,a•!i.xhnrr r„rn�.,n, / 1617 Mail Service Center.Raleigh..NC 27699-1617
11.Borehole diameter: v (in.l 24h. For Infection Wells: In addititin to F1'Ileling the Inrilt I,)the address in 24a
above,also submit one copy of(his form within +0 days of completion of well
12.Well construction method: S0,V,C construction to the following:
(i.e.auger.rosary,cable.direct pusli,ctc.) �.
Division of Water Resources,Underground Injection Control Program.
FOR W'AT E.R SUPPIN WEALS ONLY: 1636 Mail Service Center.Raleigh.NC 27699-1636
13a.field(gpm) NI el hod of test: 24c. For Water Supply K Inicetio E Wells: lit addition to sending the form to
tits addresslcsl above. also submit�onc copy of this firm within 10 days of
13b.Disinfection type: Amount: completion of well construction to the cnun1 health department of the county
where Constructed.
Fenno(i\V•I North Carolina Dcpannient of I:m ironniennd Quality-of%ision of it mcr Rcsmavc, I Rc,tscd 2-22-(lIf,