GW1-2023-02125_Well Construction - GW1_20230303

LL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
i1.Well Contractor Information:
(--.• ��ct:�P�t 14.WATERZONES
Well Contractor Name I ERO,I I TODESCRrn 1TOly
L��3 Ft � Ft
NC Well Contr@ctorCettificationNumber 7 ,p�rERCWSING for multi-cased wells OI2LTiVEtt ifa llcable
t5 W r t J PROM TO - DIAMETER THICKNESS MATERIAL
I t 1 fE: I in U�
ComoanyName
16.R NER CtLSING OR TUBING( therm it ciosed-lon )
2.Well Construction Pemdt#:_ '7�?Cef 7Lf. FROM TO I DL"M1ER I TMCKNEss I aIn'1-ERlar.
Listall applicable feell construction penttirs(i.a UIC.Count};Stag Variance etcJ % I ft. in.
3.Well Use(chesirweIl ase): ft: fL
WaterSupply Well: V.SCREEN I' i
I' FROM TO I DIAMETER I SLOTS= I TIHMMESS I MATE
I _ Agricultural VIKcsidc.,
MUM- ' aUPublic ft. I fL in.
f' Geothermal(Heating/Cooling Supply) tial•Water Supply(single) I fw in
Industrial/Commerciai DResidential Water Supply(shared) LS GROAT
I-!-
h dgation FROM to A 41SPSAL EMPLACEhIEN17 MErHOD&Ant
t Non-Water Supply Well: '. ® fk 19
= C ft. �(` rQvf
-'Monitoring ORecovery
Injection Well:
i -.Aquifer Recharge MGroundwaterRemediation
=
G Aquifer Storage and Recovery E3Salinity Barrier19.,SAND/GRAVELPACKM.i Reableier FROM I TO MATERIAL- I EMPLACEMENT METH01:
Aquifer Test OStonnwaterDrainage ft I ft.
I Expedmental Technology [ISubsidence Control f'- I fL
s~ Geothermal Closed Loop
)p) Tracer 20.DRfI:LINGLOG(attaeh additional sheets itnecessa
Geothermal eating/CoolingRetum) --Other(explaiuunder#21Remarks) kxoM TO nEpSrC�RIPi[ON(cpot�or,Iraraorss soiUrocbeve--min foe.
�
4.Date Well(s)Completed: —(C .-Well ID# ft, � y it. C-r eti"-ke
SS%Well.Locyation: n�rrft. ft. CAP=u'i•r`
(' I iG)1"�1
Facllitq/0wncr i�Iamc �e Facility Off(,ifaapppiicable) ft I ft k-• � �~ r..� .; „ �1
Physical Addms,City,and Zip R: I ft. MAR r 3
M.REMARKS
County Parcel Identification No.(PIN) .J*271
r"t` "�_-•�""�"",.
f5b.Latitude and longitude in degreesImInutestseconds or decimal degrees:
(ifwell field,Alattlongissufficient) ZZ.Certifcalo'.
` N W �
j 6.1s(are)the wells) ermanent or EITemporary Signature of Cer ifiedWell tractor Date
By signing rhisj brm,I hereby certify that the isell(s)spas(were)constructed In acc
7.Is this a repair to an existingwell: Dyes or ivith ISANCACI02C.0100 or)Sit NC✓tC 02C.0100 Well Construction Standards or.
If this is a repair,fill out btaum well construeliarr information and explain the nature of the copy.of this record'has beenprovided to the welt owner.
repairunder#2lrrntarks section oron the back ofthisform.
23.Site diagn m or additional well details:
3.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use ha back of this page to provide additional well site details
construction,only I GW 1 is needed. Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages ifnecessary.
is
drilled' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24a,For All 6.11s: Submit this fomt within 30 days of completion
1 For multiple svells list all depths ifd different(arample-3@200"arid 2 t@I00)
f construction td the following: _
10.Static water level below top of casing: �'V , (fL) Division of Water Resources,Information Processing UEat,
If isater level is above casing,use" I517 Mail Service Center,Raleigh,NC 27699-1617
{" 11.Borehole diameter: �` (in.)
;, ; • "" '•24b.For Ini Ilion Wells: In addition in sending the form-to the address
€ ©� above;also str)tmit one copy of this form within 30 days of completion
f .12.Well construction method: L r �y r construction to the following:
1 CLe.auger,rotary,cable,directpush,etc.)
Division of Water Resources,Underground Injection Control Progr
j FOR WATER SUPPLY WELTS ONLY: 4 636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)_ _ ' Method of test: 24c.For Water.:Supply&Injection Wells: In addition to sending the:
F�414 the addresses above, also submit one copy of this form within 30 c
13b.Disinfection type: G 6Amount: completion of well construction to-the county health department of the
i
where cousfru Ited.
fI