GW1--06770_Well Construction - GW1_20231023

WELL CONSTRUCTION'IIIIMORD
This form can be used for single or multiple wells •
For tnteraai Lisa ONLY:
1.Well Contractor Information: t
� Be AV.
I4.WATERZOPiES• 1 '
��
i vO t•! ch e-ksoN FROM TO DESCRIPTION
Well Contractor Name' b C)ft. n.
•
n. .-7_U.a, 1, -f'. tt. ft. 1
.4C Well Contractor Certification Number % IL OUTER CASING(for multi-casedwells)OR LINER(if applicable)
n `�' st FROM TO DiA' R. THICKNESS MATERIAL
D L L\\ !1 •€`\ 'W 0\ \\\i f-NG ,�-I ft. Li 6 R. 69in, 1 4'�.- P C
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER. THICKNESS MATERIAL
2.Well Construction Permit#: Sel'1 `Li S Q fr. ft. in.
Lisi all applicable well construction pet wits(i.e.County:State,Variance,etc.)
rt. ft, in.
s, 3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM , TO - DIAMETER': SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. In.
❑Geothermal(Heating/Cooling Supply) ilResidendal Water Supply(single) ft. ft. In.
Olndustrial/Commercial °Residential Water Supply(shared) 18,GROUT.
aOIl
PROM TO MATERIAL ` EMPLACEMENT Si THOD&AMOUNT
Non-Water Supply Well: 0 ft. �0 It" $�<<� r�
❑Monitoring ❑Recove ft tt.
'ry
Injection Well: F r it. ft.
❑Aquifer Recharge ❑GroundwaterRemediatien 19:SAND/GRAVEL PACK(if nppliaable)
❑Aquifer Storage and Recovery ❑Salinity Barrier PROM TO MATERIAL EMPLACCYIENTMETIiOD
❑Aquifer Test ❑Stormwater Drainage
ft❑Ex erimental TechnologyR.
p ❑Subsidence Control
❑Geotherrnrtl(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) •
FROM TO DESCRIPTION(color.hardness,sedUroek type,grain size,eta)
❑Geothermal(Heating/Cooling Ret ) ❑Other(explain under#2I Remarks) 0 rt. /0 ft. re.. !
c4.Date Well(s)Completed: 17.
f 0 fa '20 tt. 6c4'tad% - `,S e o
5.Well Location: ,�" BCD Li s� .bk6e Iork
' \ CiNagjt S & LOCÔ± ft. ft.ft, ft. ,
acility/Owner Name y�� e Facility ID#(if applicable) _ _
s e toGk '1"1'r�ie RA ft, fr •
-` \fr-
r'i i
' tr. it.
Physical Address,City,and Zip 21.REMARKS I t i `o "{ U Z
*c$oar•k'y --t 4 LC)County
County Parcel Identification No.(PiN) Inwlm ::cn % -':"y en.1
't's.•'�,:'-1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one lat/long is sufficient) 22.Certification:
--1 i 2.4" II.
Signature of Certified Wel Contractor i Dare
6.Is(are)the weli(s): elPermanent or °Temporary By signing this form,I hereby certify that the well(s)was(were)constructed In accordance
with 1SA NCAC 02C.0100 or/SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy of this record has been provided to the Well owner.
Grids Is a repair,fill out IDIOM well construction information and aeplaiu the nature of the
, repair under#21 remarks section or on the back of thisforn,. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple infection or non-water supply wells ONLY with the same construction,you can
submit one form. 24,Submittal Instructions:
4.4
9.Total well depth below land surface: ® (ft.) 24a. For All Wells; Submit this form within 30 days of completion of well
For multiple wells list all depths Ifdferent(example-3®200'and 2Q100) construction to the following:
' 10.Static water level below top of casing: 2.S (ft.) Division of Water Quality,Information Processing Unit,
limiter level is above casing.use"+' t� 1617 Mall Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: l�/i U (in.) 24b.For Infection Wells: In additionito sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 'racyka'c`. construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
!""` Division of Water Quality,Underground Injection Control Program,
3.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2. Method of test: IlraVdr. 24c.For Water Supply&Geothermal!Wells: In addition to sending the form to
� the address(es) above, also subtnit one copy of this form within 30 days of
l a
13b.Disinfection type: ` Amountt r" completion of well construction to the(county health department of the county
where constructed.