GW1-2021-01078_Well Construction - GW1_20210210

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Cootmc r lofor motion:µ/ 11, c
�` I U� l "/ 14.WATER ZONES
Well Contractor Name PROM TO DESCRIPTION
d 9 6s/-f
NC Well Caramel"Certification Number IS.
OUTER
CASINGha. s wdORL
TIN
Upfrmi Wei (
MM TO M MAT ERIAL
Company Neme Iq ) L
3� / 16INNF,RCASINGORT DIAM elaedl0010
2.Well Construction Permit#: b FROM TO I DIAMETE R THICKTYSS MATERIAL
List all applicable well contraction permits(i.e.UIC.County.State. Variance,etc) fl. ft. I in,
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17•SCREEN
FROM TO DIAMETER SLOTSIZE TRICKINESS I MATERIAL
❑Agricultural ❑�Municipal/Public ft R to
❑Geothermal(Heating/Cooling Supply) Mlkesidential Water Supply(single)
❑IndustriaVCommercial ❑Residential Water Supply(shared) IS CROUT
❑irri ation ❑Wells% 100,000 GPD FROM TO MATERIAL EMPLACEMENTME HOD&AMOUNT
Non-Water Supply Well: fL 6 h• �,, it!'ti
❑Monitoring []Recovery ft It.
Injection Well:
It. a
[]Aquifer Recharge []Groundwater Remediation
If.SAND/GRAVEL PACK(if PM
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM I To I MATERIAL FMPLAceMENT ME-InoD
[]Aquifer Test OS[ormwater Drainage ft fL
❑Experimental Technology ❑Subsidence Control ft. h.
❑Geotherrnal(Closed Loop) []Tracer 20.DRII.I.ING LOG •Uaea addidiadaheeb B vacua
❑Geothermal(Healing/Cooling Return) []Other(explain under#21 Remarks) room TO DFSCRIPION .br horde solutoca In e¢
O fL IL C•Yq 'So
4.Date Well(s)Completed: I i I Well ID# R U 2 C O
5aWell Location: O ft. «• J al
1 (
Facility�Owner Name Facility lDp,i f appiicablel «. ft.
1 a I X 60h erS �Gr✓h //1J'�/O/ ft
Physical Address,City,and Zip f6 rL
p 21.REMARKS
�'rGn U%�) l- Q Isi�L'
County Parcel Identification No.(PIN) ee
5b.Latitude and longitude in degrees/minutes/mconds or decimal degrees:
(ifwell field,one lat'long is sufficient) 22.Certification:
� N W
6.Is(are)the well(s): U ermanent or []Temporary Sigre� of Certified Well Formateror Date
1 l)Brzs(QlzL amsform,l hereby cernfi4hat the oell(s)wn(were)mntructed in accordance with
7.Is this a repair to an existing well: []Yes or MNoo - ` 15A NCAC 01C 0100 or 15A h'CAC 02C 0200 Well Construction Stand.Vt aM that a copy
lfthir is a repair.fill out known well construction infrumatinn and esplain the nature of the ofVus record has been provided to the well owner.
repair under#21 remarks section or un the back oflbu funs.
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 construction info
construction,only I GW-I is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: s.� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 36/ (D') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells lief all depths if different(example-3Q200 and 1@10(r)
10.Static water level below top of easing: (ft) 24a. For All Wells: Original forte to Division of Water Resources (DWR),
if surer level is shove cuing,use"-I",, Information Processing Unit,1617 MSC,Raleigh,NC 2 7699-1 6 1 7
11.Borehole diameter: Y' (in.) 24b. For Injection Well : Copy to OWE,Underground Injection Control (IUQ
/�
,} Program, 1636 MSC,Raleigh,NC27699-1636
12.Well construction method: p df y / 24c.For Water Suppl
and O n-Loo Geothermal Return Wells:Copy to the
(i.e.miner,rotary,cable,direct push,etc.) county envtronmental health epartnlent o the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells DroduciDR over 100,000 GPD:Copy to DWR,CCPCUA
qq PemtilPmgram, l6ll MSC,Raleig L 27699-1b11
13a.Yield(gpm) g V Method of test:
13b.Disinfection type:U L1 I Amount:
Form GW-1 North Caroms Department of Envim mean)Quality-Division of Water Resources Revised 6-6-2018