GW1-2021-00624_Well Construction - GW1_20210326

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WELL CONSTRUCTION RECORD (GW-1) For internal Use Only: --
1.Well Contractor Information:
a SO" P6610_1 I4.WATER70N'ES
Well Contractor Name FROM TO DESCRIPr10N
aa19 p D. I10 I 1 5 PM
ft. I ft.
NC Weil Contractor Certification Number
I5.OUTER CASING form DL= welb OR LINER H a Iicabk
G-bail flool WQJ1 T PLAMp f e , FROM TO DIAMETER TmCKNFSb MATERIAL
M \N O fL A B. in. vG
Company Name 7
16.INNER CASING OR TUBING eo[hermd dined4Lm
2.Well Construction Permit#: FROM TO DL4METER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC.County.State. Variance,etc) (t, f. in.
3.Well Use(check well use): R. ft. I in.
Water Supply Well: 17.SCREEN
FROM I TO i DIAMETER SIATSIZE TNICKNNESS MATERIAL
Agricultural Municipal/Public ft. R, in.
Geothermal(Heating/Co cling Supply) Residential Water Supply(single) ft It. in.
IndustrialtCommercial ©Residential Water Supply(shared) 18.GROUT
kri ation FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. R.
Monitoring DRecovery
Injection Well:
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK Ha IWb1e1
Aquifer Storage and Recovery OSaliniry Barrier FROM T 7 M4TERIAl. I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology ®Subsidence Control
Geothermal(Closed Loop) OTraccr 20.DRILLING LOG attach additional shuts if necessary)
Geothermal (Heating/Cooling Rehm Other(explain under#21 Remarks) FROM To I DFSCRIPPIONeo r dnea bar wil/ruek type,ariiiii Am etc.
(t, ft.
4.Date Well(s)Completed: Well ID# H. O tt•
5a.Well Location: f 0
ft. a All
ft.
-burt Pow el
it. ft. a e r
Famlity!Owner Neme Facility 7Dk(if applicable) ft. fl'
_566 La Kew60J r�1 . oar O4Ks, ft. ft.
Physical Address,City,and Zip ft ft.
S�r t 21.REMARKS
County Parcel Identification No.(PIN) �1pk
St.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one[at/long is sufficient) 22.Certification: _
N W � -
6.Is(are)the well(s)56rmanent or QTemporary SignatueofCcrtified Well Contractor Date
By signing this form, I hereby eertayirthat the xrll(s)was(were)constructed in accordance
7.is this a repair man existing well: nYes or &Ko with 15,4 NCAC 02C.0100 or/5A NCAC 01C.0100 Well Comtmcrion Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy of this record bar been provided to the well owner.
repair under k21 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
constructiop,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details, You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I O (fit-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiQerenr(example.3@2^00'and 2@100') construction to the following:
10.Static water level below top of casing: .1 O (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:_ (in.) 24b.For Infection Wells: In addition to sending the forth to the address in 24a
�d above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: r/ construction to the following:
(i.e.auger,rotary,cable,direct posh,e[a�
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ��t 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)� Method of test: 0 24c.For Water Supply & Infection Wells: In addition to sending the form to
L the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: r, Amount: completion of well construction to the county health department of the county
where constructed.
Form GW4 North Carolina Department of Environmental Owiity-Division of W.wr Resources Revised 2-22-2016