HomeMy WebLinkAboutWELL-05-2022-171623.TIF 'ESL CONSTRUCTION RECORD GW_1
For Internal UseOnly
1.Well Contractor Information:
Kyle C. Shaw .
Well Conrracto..Cane l 11.z1'ATER ZOOS
fC FRo?I I TO DESCRIPTION
4521-A 4101In fv -
'.0 Ci'cl[Canttac or Cat it:catior. unoc rt tL '
LLC 1;-OETER CASING for moll!-cased Iveils ORLLN R Ira [inble
Advanced Weill Drilling,
FROtit . TO �tiI DLETER TITICKNESS MATERI'L
Company Name o f rt. I 1 / /J ft 6 in• I Heavy PVC
2.�l'eR Construction Permit �cps •d�� t'_. 1Kp 16.I NER C;�SLNG OR TUBING(••'thermal closed-I...)emit#• FROM TO DLI\IETER
List ill?npp?iea5le cell eonsrnlction renntts(_e.!MI'.Ca:nr.T.Slate,1•crfon,<c:c i ft tC^~ attTER1 tL
ft. I n.
3.Well Use(check well use): r fr. n ia�
Water Supply Well:
' 17•SCREEN
A.lgticulhtral FROMI TO DIa.1W rR SLOT SIZE I THtCI,Ti SS \I,ATERIAL
❑Municipal I'oblic
LtGcotliemtal(Heating Ccoling Sti tiv s �; rt. It. in.
Pf ) l9Re_td_ntial'r.ater5uFplti�(singlaj
C�duslrizUCommerciai 2 ft. in.
❑Residltia)!Water Supply(shared)
❑lrriRation 18.GROUT'
❑Wells>100.000GPD FROM TO MATERI En ?L tICEL:E\,•T.MtETHOD&A1tCt�7 J
Non-Water Supply Well:
°Monitoring a rL I
�� rt AL 3enfonRe Poured
Injection Well: GRacot'ar�' I fir ft.
A:Aquifer Recharge ❑Groundwater Remediarion ft } it
❑Aquifer Storage and Recovery1 is..SAND/GRAVEL LPACK(ifappllalblel
❑SalinifyBarrier FROM TO?
QtsquiferTesl Dr 1 ttL f TeRt.t EMPLACEMENT MET
HOD EI DOD 1
❑S[or,umater Drainage rt. I 1
°Experimental TxltnoIogc
❑SubsidencaCoDtrol ;a f4
CGeathetTltal(Closed Leop) GTracar !-
EGe tltennlal(Closed Le
allno 20.DRILLING LOG(attach additional sheets Ifrecessorr)
- Return) DOt}7 -l�.��11iR;m3ar='1 ftztnarl:s) —rao\t I TO I DESC RIP ON(color,h:t-dnecs,se Wrack type,5aIn dzr•etel
i
1. Date Well(s)Completed: J Well I r /� ft
• I IT rt 0 t!
So.Well � I ��G' X
Location: lS 1105- (c 4 f �7oc (i f� .'�
n o o dos f` !I t 1-•+ rr_ 1 'oft
F°cilir:l0nner Name �u _j ft- ft /1� �� ��E
Facility II]=(ifapplicobi-) `i 1 N.P�
Physical Address,Ctn•.and Zip
Ft. ft. 7
23.REiL-aR1:S
County
Pad Identiucalion:{o.Ip1;
Sb.Latitude and longitude In d ceslrninutestseconds or decimal degrees:
(if well field.one Lrilene is suurictent i
` �'/ J y, b`'Y`72 /f ?2. /.2.Certification:
- � U /- V `-t -tfs ��/
Is(are)the wen] s : _PcrTrulncnt or tt ✓ �� " r
G. Is > (r -J1�a3
CTemporen Sigrnar eo:C�(Fied'•t•el;Contractor au:
1•Is this a repair to an etisti •%;•agninp rhis)brnc Ikerabr cemf:•drat the.reliisi wastatrc)const,•ticted in cccorclmre tiny
D well: Cie or Le No 15.;.VC.;C G_C.0100 or 15.2 VC.JC 02C.0200 I t'el t Cottstntcr,'on Slander&and Mara copy
lfthis is a repair.IOt ow knou n hell cauu•act•oo Iiltbm anon and e:vloir,tiro nature ci ti;a
repair rioder-,21 rapt+•o-kr section or on due hock of lornc 4%tics retor?lntt boar,nrtn rdcd ro rJ J gull°lunar.
g.For GcoprobdDPT or Ctrsrd-Loop Geothermal c 23.Site dianrtm or additional well details:
th rmal Wells having the_ante You may use the back of this page to provide additional well construction info
construction.only!OW-1 is tided. Indicate TOTAL NUMBER o;:van is (add See Over in Rernarl;s Box).You mayalso arach additional Des if nec:s sar-
P
9.Total well depth below land surface:R-Q '1 SE B�IITT.aL L�STRI CJ IONS
Formulnplc xa&list ail d:pdtr if d?(lercix(csorl1de-S'F 200'�n::_- 100' (ft' Submit Ibis G1i'- z
1 within_0 days of well completion per the following:
10.Static usenet level heron top of casing: 6 {) 24a. For All Wells: Original form to Division of Water Resources (DV R),
If tinter level is above caring,use •• ('Li Information Processing Coil. 1617 MSC.Raleigh,NC 27699-1617
11.Borehole diameter: 6
Cm.)
24b.For Injection Wells_ Copy-o DP:•IZ Underground Injection Control (LUC)
Program. 1636 MSC.Raleigh.NC 27699-1636
�j
12,Well construction method: ye,j f- Pisa
(LO auger,rotor]'.cable,direct push etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to lire
FOR WATER SUPPLY WELLS ONLY: county environmental itcaltlt department ot•the county ubere installed
24d.For Water Wells producing over 100,000 GPD:Copy to DWR.CCPCL14
13a. Yield(Om) r`'L Method of test: Air Pem7rt 'roerant. I6I..l SC.Raleigh,?fC_'769St-16l i
13b.Disinfection tw-De: HTH II +
.amount: f I bS 1