The URL can be used to link to this page

Home My WebLink AboutGW1--05214_Well Construction - GW1_20230818 /WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1.Well Contractor I orma on: .f-/aL.V ljyLio „:„. Fl!.,,,.'LQ7!iESjaktT .3 .,}_..y„. ,,t h. :,,.w`".../.t:_;,„,T.....�T.>., :t�_,.: Well Contractor Name FROM TO DESCRIPTION ft. ft. t3 // • W A ft. ft. NC We/)}Contractor Certification Number //�� _� .l'S}tOI)R'kiRICASINNCyi(fd�;inu)igeitied4elli)tOR+IONER{(ititt teabla)l _'. ''%i. /- ,r me ` //L)e I) //,,� (2,' Li-K.., n c FROM TO DIAMETER THICKNESS • MATERIAL . ll»fi( J tit /�W t 1 ft. f. �,/;LC la• s u A-ot.i P IJ�i Company Name • 16 1NNEztCASI (y`.fORs1NBIl1TCi(QaO.thliiiiiiilfel0iii looP)r';Sz ii4Mrtti l x,. Ki*x 2.Well Construction Permit#: FROM TO DIAMETER ; THICKNESS MATERIAL List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. In. 3.Well Use(check well use): ft. ft. In. Water Supply Well: %17 SCkEENr,�, : [s'w,z�.? ,..Y,.:."i, ,i:.,r v 2 . ; `.,....f S ..i..., • FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL - 0Agricultural QMtmicipa)/Public ft. ft. in. Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft, g. tn. Industrial/Commercial rResidential Water Supply(shared) i ' 3L r, x wh ,��; ,. f tx , fit):CRUUQ.�'r 6 _s_=:s.a, 1.. . r..�,.,;.Y.,.. .s. ?r. :.1... .k fib yc':°r.. Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMONNT Non-Water Supply Well: d H' ft. b&U�.)'ll rt; ill /j,(cj - D iAr Cjimonitoring Recovery ft. ft. J Injection Well: ft, ft. Aquifer Recharge QGroundwater Remediation r d9.SAND/GRA., (1'�ACKAit iiinnea le)ti' r.,t,r_ .::.l: ,s`u .: [pAquifer Storage and Recovery QSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD 0Aquifer Test `■Stormwater Drainage ft. ft. DExperimental Technology _.\OSubsidence Control ft. ft. OGeothernal(Closed Loop) ' DTracer t£2(1f4) 'I G T30:G:7at"tief(additlOSisil,aFtgdti}ifiiiceieory)YL -5a" -",t r. } Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) FROM To 2CItIFrION(coIoehardnc8a,eolUrock type,grain dz,eta) �J y irf G(aY - 4.Date Well(s)Completed: /'1 t/-" Well ID# qij ft' .4, t' /,j rQ,�j 5a.Well Location: f t' n' �J r- R o.. ., ...t.. ' ft. ft. I..\a L.E E �/ i1/Gl—au��l.1„-� �rpr LAG D Facility/Owner Name. Facility ID#(if applicable) H' ft. AUG r 1 o n'}O (5 /�fi/r Yi 11 .S .1)r, ft. ft. f J to Y xr LltteJ Physical Address,City,and Zip ' ft. ft. in rrnati- n Prnc&.ii°.g UR# M L n d w4_fl 141riREMOKS .ski: Ig,{. z Y } �. .. ! .. . . County Parcel Identification No.(PIN) • - 5b.Latitude and longitude-in degrees/minutes/seconds or decimal degrees: ' (if well field,one lat/long is sufficient) 22.Certification: t 'll COS- N "II' 674/d�G W PA714 ;4- �.� 7-°' Signature fied Well Contractor Date 6.Is(are)the well(s)hA •ermanent or b Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: ()Yes or 1)K1No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a If this is a repair,fill out known well construction information nd explain the nature of the copy of this record has been provided to the well owner. repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details: 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells . construction details. You may also attach additional pages if necessary. drilled: SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: e,. (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths if different(example-3®200'and 2Q100') construction to the following: • 10.Static water level below top of casing: lO 6 (ft.) Division of Water Resources,.Information Processing Unit, If water level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter:- (t? (in.) 24b.For Infection Wells: .In addition to sending the form to the address in 24a I� -�- above,also submit one copy of this form within 30 days of completion of well Y 12.Well construction method: D/Li--V't! construction to the following: -- (i.e.auger,rotary,cable,direct push,etc.) / - Division of Water Resources,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 13a.Yield(gpm) 14 Method'of test: QI r 24c.For Water Supply&Injection Wells: In addition to sending the form to Amount: C-LL�5 _ comp a �n ofcweell�construction to the copy this form withinnt 30h days county k.(6 1 / the address(es) above, also submit oneof 13b.Disinfection type: C.��6 Y I KO _ � p county health department of the county