GW1--03982_Well Construction - GW1_20230612

WELL CONSTRUCTION RECORD(GW-I) For hitemal Use 01AV:
1.Well Contra I I f ornktluon.• 14.WATER ZONES
""ell Cmitmewr Name FImNl TO DesC lirm),li
ri Z�—o ft.
ft. ft.
NCI Wefl Cotlirmt 'Certification Number
15.OLMER CASING(for d I'v9s)OR J. (if dp_Rcdbw)
FROM ITO T 1`51 L&exlE'R.R I 'MICKNESS MATERIAL
ft. /5V ft, I
✓
144-NINPR CASING ORT CASUBINC lti2aliter
2.Well Construction Permit ii:%M— 4 FROM —To I DIAMETER rRICINNEss MATERIAL
List all applicable wett construction Tenpils(i.e.UJC,Coitizi-v.State,Vilriarive,etc.) ft. fL in.
3.Well Use(checli well use): Et. ft.. --ill.
Water Supply Well: 17.S C R E UN
FRON'l- TO DIAMETER SLOTSIU THICKNF.ss I "I;%TFRmJ.
JV 5C_
___F
:lGeollierilial(I leating/Coolin.Supply) k Ka.t1'1C11',111'1"ial Water Supply(single) ___
Ind list]ial/Com Illptrial [31tesidential waler Supply(shared)
M GROUT
rao'm _J�K) NIATERIAL
FNIFIACEMENI'MM101)&AMOUNT
Non-Water Supply Well:
L)_2
AlonituringnpLcovelv
ft. ft. 64;"g_s
injection Well:
ft. ft.
Aquifer Recharge Remediatioll
19.SAND/GR AVEL VACK
lAquifer Storage and Recoveiv osalilljty Barder FROM .11, MATFRIAL mPi.AcFmF.,4'r NiF.,mrso
Aquifer Test L)raivage
lExperiniental Technology [)Subsidence Control ft. ft.
Geolliernial(Closed Loop)
FROM To DE.SCRIMION(Lular,itarth—,saTr rain sits.ere.)
Geothermal(IlLating/Coolimp-Murn) n0fllpr(cXplain under V21 Remarks) ft.- ft. 3" olir.g
4.Date Well(s)Completed: Well ID4 ft 17 'o ft-
5'a' c Lot. t.
a.I let) a
i 15�r
I /A ft ft.
X.v
f
ft. It.
Zip ft.
UmIm 21.REMARKS
County Ideptifici,ti,)II Nu.
5b.Latitude and longitude in degrees/minutes1seconds or dedinal degrees:
(if Wel"field, au 1,101flag is%tiffidelit) 22,Certification:
N W
G.ls(om)the well(s)dPor-oanent or [3,1'emporary Sigllvattlte of CNI11)(ml Well CrillLnictur, fate/
By signing this ftxm I h,rehy certi,51 butt rite wells)was(were)construe led in accordance
7.Is this a repair to all existing welt: [Dyes, or CL71/No u.,Rh IFANCAC 02C.010 I),,;15A'VC IC 172C.0-100 tI-VI Comirixtion Standards aiyelrdwt(I
It[III,is a relish,!ill mit ka"'wn M;'W"IrImtior,1111"InIal"on'u'd expl.in file nature ofthe rof v of this record hm firm pruvio'cd to the weli nu*ncr.
rrp it under ?J romarkv.scclivn of of,the back ofthis form. 23.Site diagram or additional well details:
B.For Geoprolie/DPT or Closed-Lurlp,Geothermal Wells having die same Yoll May use die back of this page to provide additional well site details or well
construction,only I GW-1 is needed. indicate TOTAL NUNIBER of%yells construction derail::, You may also amicl)additional p,,-Ls if riccessaty.
drilled:__ SUBIMITTAL INSTRUC rIONS
9.'rotal-well deptli below land surface: M2 -1. Ta
r or Ali Wells: Submit this form within 30 days of completion of well
Forplultipf"wells list oil depths itd[rj?rent(avurnple-j 6 y' gl construction to the following:
10.Static water level below tot)of Casing: Division of Water Resources.Information Processing Unit,
If water level Is above casb,y'im,",/" IIS17 Mail Service Center,Raleigh,NC 2709-1617
11.Bol-elloje tfijituel or,. 24b.For Injection Wells: in addition to sending the form to the address in 240
above• also submit one copy of this forthwithin 30 days of completion of well
12,Well Construction Illethod, construction to all,followilig:
Ox.mjger'FCAaty.Cable,tutect pi"I",VW.)
Division of Water Resources,Underground Injection Control Program,
17(311 WAXER SUPPLY WELLS ONLY: 1636 Mail&,rvilce Center,Raleigh,NC 27699-I636
13a.Yield(Cpm) 1 Metliod of test: J T 24c.For Water Surinly&Injection Wells: In addition to scildilli the forl"I to
Ow addresses) above, also submit one cop), of this fonn .-Jthfti 30 &vs of
13b.Disinfection type. v 0 7 Amount: Completion of well construction to file County health department of the. county
vdieiv constructed.
Folln C'W-I 'Nulift Carolina f?"ImIlvietit of Envir,,timental QuaRy-Division of lVater Rcw,uice, Revised 2-22-201C,