GW1-2022-00127_Well Construction - GW1_20221219

WELL CONSTRUCTION RECORD For Internal Use ONLY: 4
This foroicsn be used farsinea crmnitiple wills
1.Well Contractor Informs. n: A ,
FROM TO TDEsoumoN
WellCounactorName .R 3 fr d-ovue "011h•k 1/ �-
a3-iz-A NeW�-3ell6 R R f
NCWetlCnu=mrCertificaionNmober 15:OUMCASING t'ormnit-c=Mesdh ORLINER d'
R FROM TO DUMErM 1 7MCKNM
vu MATERIAL
ft S L� 'L R im 1
CompanyNmae 16.MER4ASiNGORTUBDVG -
g •PO D7AMETQt 1 TMOCNESS MAMMAL
2.Well Construction Permit#: !-10'I is r/ im —L,f 4 �C
Latatl applicable uvBpemdts(Le�Stat4 Varlance,6rfedion,etc) r
R S, R �j in,I -17gf 4" /J
3.Well use(checkwell use): 17.SCREEN t
Water Supply Wee: Fft
TO DIAMETER SLOTS TIM..IO ES.S• 51ATERUL
❑Agricultural ❑Mtmicipal/Public z fl
>a �d❑Geothermal(HeatinglCooliug Supply) ❑Residential Water Supply(single) in
❑InduslriallCommenhl �idential Water Supply(shared) IL GROUT
_ FROM To TFSiAL ENUnACErAMWMEMOD&AM,0UNr
❑Irri on (� R tie e GVL
Non-WsterSupply Well: R R
Monitoring ❑Rerovery
Injection Well: R ft.
❑Aquif-Recharge ❑GmundwaterRemediation 19.SANDIGRAVELPACIC if ®hie
FROM TO MATIHiAL EMP"CEPITENrEIETROD
❑Aquifer Storage and Recovery ❑Salinity Barrier R / ,
❑Aquifer Test ❑StonnwaterDrainage R R
❑Fanperimental Technology ❑Subsidence Control
20.DREUJNG LOG nttaeh2d&UO=315heetsif
❑ cothenmal(ClosedLoop) OTracer FROM TO DFSCRWnONm r.ha,dmaaoilhoelr ru.ete
❑Geothermal(Hea&dCooling Return) ❑Other(explain under#21 Remarks) R 7-6 ft-
4.Date WcH(s)Completed: Z% Well ID# ft R •1 &-ko _
Sa.Wee Location: �� ft. lO d R '/)Y_ 1¢/l�# 4, /Lo
6Ar i+e &-JM�S Z,C.� ��" l(o R ft.
Fac7ity/Ow=Wame Fac ty m0(ffappli-Me) M
AJ
(_ Ili ( '" ��'_ f�i�tru%S
PLysied Address,City.andZip 2L REMARKS i r i )
County AucclldeotifrmIIanNa(PlN) is'st 5' urift
5b Latitude and Longitude m degitedminuWseeonds or decimal degrees CertiS n: /- y
(fwell field,one b9long is sulSeigd)
1� i! W G�e� U� � /L•-rz--�Z
Signtuie efeertilied Well Contractor Date
6.Is(are)the well(s):Zf.,-,manent or ❑Temporary By signing this form,l hereby cedify that tie nzll(s)Was(were)camtmcted in acwrdanea
with 15ANCAC 01C.0100 or 15A NCAC 01C.0100 Well Ca=vzetionStwuhrds and time a
7.Is this a repair to an eEisdag well: Oyes or lag. copy oft,u rewrd hm been prmvFed to lbe welt owner.
lftiis isa repair,fill oatknownWd1 cv v=von uformarion and erplmn the nature of&e 23. '
repairtmderRMmmantssecdonoron the b=*ofd&fomc YOSitediagramor kofthislweeoprota:
9 You may use the back of this page to provide additional well site details or well
&Number of weds constructed: l construction details. You may also attach additional pages'if neressaty.
For mdiiple injection or non-irarersmpply wells ONLYwitr thesameovn*Drt m+,you sun
SU$Mf1TAL IIVSTUGTIONS
sabmil onefonm R Total well depth blow land surface: (ft) 24.For All Wells: Submit this fmin within 30 days of completion of well
Forandaple well;fin off de 4z9'differrnt(--ple-3@200'and2@100') construction to thefnllowmg
I0.Stff is water level below top of casing: ( (M) Division of Water Resources,Information Processing Unit,
lfrvater level is above casin,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
•.
11.Borehole diameter / (ia) 24h.For faiection Wells ONLY: In addmon to sending the form to the address in
24aabove,also submit a copy of this form within 30 days of.eompletimn of well
12.Well cosshvcfioa method: construction to the following `[
(Le-anger,mtay,table,ducdposk etc.) Division of WalerResosrces,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY 1636 Mail Service Center,Raleigh,NC 276WI636
Ma.Yield(gpm) �! hiethod of test: 70 Ji*V 24t~For Water Supply&lniection WeLL.
,gyp !/ Also submit one copy of this form within 30 days of completion of
136:Disinfection type�/("''� t r` Amount! rJ'T y well construction to the comity health department of the county where
constructed
FormGW-1 Ninth Cmob=DQ=ummnofEmmmncntavdNamalRewmcm—lhviionofWaterRes1.1 Revised Am 2013
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