GW1--03341_Well Construction - GW1_20240603

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W ELIA CONSTRUCTION RECORD For 1>aenml use ONLY•
Thin torn pin be trued forsingle or amldpk wells
1.Well Contractor Information:
-/-- yJ t `. (/{' r 114.WATER ZONES I
''"!('.`,/ .1 �.1",, lK 7_ "„ . ryl /i._._ .. __.-_ i FRo TO DESCRIPTION
Well Conuact r Name J IP?
ft' Y.-s
-a_t" 'f'6-i)N1 7 60 `4- 7 3 d:, PI(
„2./w- '7 . 3 i� dit. r,4 icvn
IC;Well Contractor Certification Number 15.OUTER CASING(for mult4cased wells.OR LtNEE(ff applicable)FROM TO DIA
METER AMETER mamas MATERIAL
McCall Brothers, Inc. fr. ft. in.
Company Name 16.INNER CASING,OR TUBING(Seethsrtaal taaaad hap)
FROM To DIAMI TER TRICKNESS _MATERIAL
2"Wen Construction Permit ft:
: D rt ft. / tn. 3 75 )j/c_
l ice all applicable well construction permict(re Comm).61ar..Pe!i.;:rrr.etc.) ft rt. GY in. ►.
3.Well Use(check well use): )7.AGRIIEN
Water Supply Well: _ FROM TO rosatiSRIR SLOTNis THICKNESS MATERIAL
ft. ft. In.
L!Auriculturel f:1Mtiutc•pal; uhlic: _
tt. rt. In.
i
l iCeothertnal(Heating/Cooling Supply) 13 )annual Water Supply(single)
IOlndustria(i'Cointnercial •ORe-iden,ial 41.ater Supply(shared) 1H.CROU f
FROM _To _....---...._...MATERIAL. liAEL4CEMENTMBTH°DiioAMQj.wr
Obligation rt ft7 -
I Non-water Stilly Well: t /�j1`` 7 / Yv C,y,
rt. n.
'Monitoring CJReeovnry !! . .6 jS-
Injectioa Well: it
JAquifer Recharge LJGroundwai:T Retnediation 19.SAND/GRAVEL PACK(If applicable)
FROM _ TO I MATERIAL EMPLACEMIEfT METEOR
........-
DAquifor Storage and RecoveryRecovery rjsaliniryila•rir"r It. ft.
DAyuiterTcst DStormw•atct 1)rainagc ---
ft. ft.
Jlxperim ntal Technology flSubsidr:ncr Control
20.DRILLING LOG(attach additional&b eets if aecapary)
DCimtthe al(Closed Loop) DTraccr FROM TO I DESCEIPTRO--_barams,rotliracttape, da,eer.l
7.1Gcothcnnal I Coolie Return) r7Othcrtex lain wider 921 Remarks) D tL -.7 U /�n /
�fl.4.DnteWell(s.)Ctingeted: ,`� r.._ .. g:: - i »'((�cC/JVS �RttllLoeatiolt: �.,a ;,t S/*nJ 4e.,zi, d41-1,,
f1.
/0/9%L - L 7,4/(z�x. 49 j°G)p y6Q`65.- S' v "n t -
ft. �-1�N;/ ,
Fa-Hoy/Owner None F'atal),IIVIt•ifapplieuble) r_
ft" 7, ft.
Pleysics`AAtdrnsa,City,and Zip 21.RRMABitS 6 ' • .•'
C uul`I'ty Y Parcel la.-nlirieatinn Nn.(PDT) 1 ft.,t! _ 2024
tb.Latitude and Longitude in degrees/mittureslsecond.a decimal degrees: i
fife:el1 field,one laNMng is sufficient} 2Z.Certification: }ii.,�i ;:r,.` {..,•.j v t
rl r D
.�,�i al Sri �;1 i N 1�/ s�s7l 7._�$,. w _._.._ _ r. �' __ ... _ .__ _ '13'
'� z
S ire of Ceitr Neil Cenrttaotor 1'D'ate
6.is(are)the well()): OPermanent or ❑Temparivy
By signing this form,l hereby enmity that the we(*)was(were)constructed In accordance
with 15A IfCAC 02C.0100 nr 1 SA NCAC 02C.0200 Wen Construction Standard:and that a
T.1s this a repair to an existing well: D Yes at (Peri copy tit this meant has been provided mike well owner. 1
if this la a repair,fill out know:welt construction inforeuainn owl•-rrloi,the'.n ere nfthe
repair under 021 remar#sseelion or on the back of this farm. 23.Site diagram or additional well details: 1.
/ You may use the hack of this page to provide additional well site details or well
S.Number of wens constructed: I construction details. You may also attach additional pages if necessary. •
Farr multiple injecttoa.or nos-aster supply tee/11 Oft Y...irk at,'mew ennttrucrlan,you con
whoa(one form. 24.Submittal instructions:
9.Total well depth below land surface: (f(,) 24a. For All Wells: Submit this form within 30 days of completion of well
Pop,multiple /is he:aft depths iIafferent(examp a- .rr'an 1;n7120 ,•T n;lrtai construction to the following:
10.Static water level below top of casing: / O 2-- - _ (ft.) Division of Water Quality,inlbrmation Processing.Unit,
!!,.rarer level is oboverasing,use"-" 1617 Mail-Service Center,Raleigh,NC 27699-1617
/ t i
11.Borehole diameter: C.>/� fins) 24h.For Injection Wells: in addition to sending the ftmn to the address in 24a
jQ 1, l above, also submit a eppy of this form within 30 days of completion of well
12.Well construction method: / ' /R iltj construction to the following:
:i.e.auger,mtaty,tabu:,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(g(tm) __-- Method of test; ,�}1 n l�'� 24e.For Water Supply&Geothermal Wells: In addition to sending the form to
/'.'_1 �,- ._ - -•- the addresses}above, also submit one copy of this form within 30 days of
l 13b.ilisittfection type:4C,1111 A C Antonin: ,t�>� completion of well consmlction to the county health department of the county
_ where constructed.
Pore,(iW-I North(;::rob.+.•I'.T...ntrnenlorEnv:ronm at and NaiuralIteaoun:ex-•Diviaior.ofWalerQuality Revise:4Ian,2N3.