GW1-2022-07666_Well Construction - GW1_20220818

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Print`Form�
NYELL CONSTRUCTION RECORD (GW-1) For Inicroal I Ist:Only:
L Well Contractor Information: 7
l� i �/1(/`�✓E W t rr1�uP:'��1 l i( scCar r ; '14.W FROM
ATER ZONES In' cHlrru,�
WcR C m,!wonr Numc
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VC We11 C'Iva,uretrn t'ollkmwn Number 15.O(1TF;R CASING for multi-cased w ils►OR LINER if a licahte) _ _--J
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I'r,u,prnty Vantc _16.INNF,R CASING(1R TUBIN(: •eulharmal clased•Inn
?.Well Construction Permit ff:(e• - 4 p_.OryVW\ rRo\I l'r) ulA IVLF.H_LTllwKNi-S., \1.1'fFHI\l
/.r.r,rll n/r;•lr,.ri+h r.n,.nn•:r«+r nrt.rrr (`(/ r.w!rr u: . 1',n,m,, rrr ft. ft. in. I
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3.Well Use Ielleck%%ell use):
17.SCREEN
Waler Supp)v Well: I'HO)I ro uf\an:"fl:ft SI!Il'SIT.E '111ICKNESS AIATERIM,
Agricultural It.
trcnthemial(llcalmu( -(late Supplyi ORcsidcnual\Valcr Supply(singlet ft. -- ft
Industnal!C'onnnerct;d DIResiticnual Water Supply Nulled) Is.GROUT
Glt(Illl' _
Irrl alien rm 'H(1\I r(i— \L1'lhltl4t. t?119 \t'F:\thy"1 ptF lllt,ttX A�t!11+�1
Non
Supph Well: - ft.
4i uutnrutg QRcct,vcr_1' ft. ft.
jection Well:
In A • - It. ft. -Aquifer Rcrhaigc �Grnundtvalcr Remerhau„il
n^2 SAND/GR,1VEL PACK(if applicable— __ 1
Ayml'crSuuapcendRtcovcry tiahl hti;u,r,Gl:_ FROMru +:urut\L_ f:alet\rtauvl\nini:.n _
AlutferTest �'Su,rntwote, I)ra;d14 — ft.
11\pt•6mumal Tcdmo!vc•, os(lbstdcncc Cont.;,l — It. ft. t
Gaodu'I'ntal IC`h+.ed Lor,p) QTraccr 20.DRILLING LOG attach ellnnul sheets if necessan) _---f
14 OM l'(, IIi,St llll'TlllN i,nlnr.Fardnesc_>oiL'rack�,n,•.crui iir,etc-„.i
Geuthermalfllcatin+,?f'uu!iryRrlurn) C)thcrlcgthnnnndrr''`I Rrnunks) ft. 6
4.Date"Wcll(s)Completed!7 ZZ- \fell1i)N
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So.Well Location:
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I ,�.riay t,a;r.r'.:+r!¢ hatriny IUr,rt upph,able) -
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21.REMARKS
!1 Gil✓�(�..J J o✓ -----n --- /� ---/-- 1`
('nnntr 1'mcd Idrmiticanon No(PIN) -Cli,
Sb.Latitude and longihule in nr t)ccinutl tlegrecs: -�-----_--{� ✓ �pp-L-•--'----��=.f-=• _J��
III"eil hod. ,nc tat 1.+nc <a16­1 ti 22.{.'el'(I c%lioll' r �'-L 1. /A/ oN)/'Nt,.'.�J (?�C'/C_!I C�✓1`
35 mDgss N �xa_ z3Lr378 �f,�Ix
6.Islarv)the cvellis)OPern,ancnf or CWTempurary Sien:auic of Certified Weil Osniractar t)alr
16 +rt,rin flny[,_rn. f hurl, nhl Ihrn llr. r.r4r r s ,.•r:•!,.r.r r .-,.r,au„
Is this a repair fo:ut rusting well: ®1'es or I'rNn uwh lAl \C,l('P ( ill riu n I s a YU I nit n,'n0 4,11, -1-1 rrr„r:.ro f a ,af:.,•,r.:
If iln,r,a-two, f"iP:ur1 trnnry ur 1',nrnn nr ono n!/n.nnrnnn:md•-,i+;ur,+Irr nulnr.•r/!hr rqn n!Ihr,rrrm,l hu.lice,pu I,lydjp,rhr urtl"'w"
._ifrra•nudrr a,N rr.n:rrr ..,:.nr;...ne rir h.e F..;thn!...rrr t
23.Site tlingr:un or additional\v ell details:
9,For(;eoprohe/01'f or(:losvd-Loup(;eothermal Wells having the smile You may use th hack of this page to provirk addiliol.al .coil site tletad.r)I ,vell.
rner,•tnupnn,onlviCi)�-Ir:.r,ecdrd hidreatcTO"r:V 1U\iRltltn(tvcll> conshlictiondetails. %'ountavalsoatfirh:u!d•non,lliv!_esifnecesvary
drdlyd. SUMMITTAL INS-fHUCIO INS
9.'Filial well deftth heloo land surface: _ (I't.f 24a. For All Wells: Sulmm this f ant m-Ir:: ?n d•t n!'r„m,:,'rr
l:rr...... r;•L N,Iry.Ai;i.?rdr.r drt?rrrm r.,:miph °(ft) wd-"rr/nPt construction to the following:
10.Static water Ievel below top of casing: (.It.) I)ivision of Water I(esources.Information Processifir I`nit.
1617,Mail Service Center.Kalci;;h.NC 27649-1617
11.Borehole diameter: (in.)
241).For Injection Wells: In nddiuon to stuttinu rile Ihrm to rite:tdda•s,ut as
r
ahnvc,also submit one ropy r,f;thi> form :+ohm zit dap= of,ctwnplr;rm of Wei)12.Well construction method: S U.,/i L construction I+,the fbllutwne:
Division of Water Resources.Ihtderground Injection C'nnU•ul Prof rant.
FOR\YATICR SUPPLY W E LS ONIN: 1636 Hail Service Center.Raleigh.NC 27699-1631,
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13a.Yield Igprnl \Icthud of test:_ 24c. for Water Supply tC Injection Wells: In addition to sending the firm to
the atldlcsq") above,
also subnllt „ne cope of this itimi within ?0 days of
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13b.Disinfection type: Amount: compiclioll of n well cuslrucumI to file county health dcpanntcnl ill'the umalt%
where constructed.
Forst t AV-I North('a.r,hn..Uc,m ntcnt•+'hut,«,nun.ntal 1)irnluq-17n iatnn of w'stcr Hr�:,,r�rci;
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