GW1-2021-03156_Well Construction - GW1_20210625

_.sx:CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
t FROM TO DESCRIPTION
WWel�ractorName
l ! ft.J ft. ��
i ft. rt. G
�..,.0 Well Con o Certification umber 15.OUTER CASING for mulll-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
✓. Cs� r t) ft. I�5 it. 4,5GJ L f�.
Company Name 16.INNER CASING OR TUBING fizeotherWall closed-loo
2.Well Construction Permit#: FR DIAMET THICKNESS MATERIAL
List all applicable i4wh'construction permits(i.e.UIC Counoa State. Variance,etc.) ft. in.
3.Well Use(check well use):
Water Supply Well: 17.SC EN
FROM TO DIAMETER SLOT SI?.E THICKNESS MATERIAL
Agricultural �Midcntial
ipal/Public J ft. c2Z ft. a In 3 s/ ya '
Geothermal(Heating/Cooling Supply) Water Supply(single) J' ft. In `I
Industrial/Commercial DResidentiai Water Supply(shared) 18.GROUT
Nlrrigation-_ FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water ply Well: to ft. 5-- tt. Q v/
Monitoring very ft. ft. j
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test / Stormwater Drainage - Et- ft. G Uv-
z
Experimenta=sed
y DSu ence Control ft.
Geothermalp) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothe 1(Heatin Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION cator,hard ss soil/rock tarn size etc.
/ ft. ft.
4.Date Well(s)Completed:� ! Weli ID# ft.
Sa.Well ocaHan: � ft. v ft. ez
4- t
Nov
ft. ft.
actbty/Owner Name Facility ID#(ifapplica6lc) S
_10 4 L J ft.
( UfiW=AAC2J
IA
Physical Address,City,and/Zip � ft. ft.
/ly WU/V 11V 21.REMARKS } '
.IG((j
County Parcel Identification No.(PIN) :'. Ci e11O'VI
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaVlong is sufficient) 22.Certification:
to W
6.Is(are)the well(s) Permanent or FITemporary Signa re Certified Well Contractor Date
4v signing this form,I hereby cerlifi that the well(.) was(were)constnrcted in accordance
7.Is this a repair to an existing well: Dyes or j No with 15,4 A'C,4C#2C.0100 or NSA NCr3C 01C.0200 Well Constntction Standards and that a
if this is a repair,fill out known well construction information and explain the nature 0j'the cop)'ofthis record has been provided to the well owner.
repair tinder#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
k.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
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: f SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ,tr (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For nurltiple wells list all depths if'di�erent(example-3@200'a}nd 2@100') construction to the following: �
10.Static water level below top of casing: < (ft.) Division of Water Resources,information Processing Unit,
lfwater level is above casing,use"+//" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: CSC (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
�} above, also submit one copy of this form within 30 days of completion of well
12.Well construction method )st/1u�1 �J' construction to the following:
{i.e.auger,rotary,cable,direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
DR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply & Tnection Wells: In addition to sending the form to
�—`— the address(es) above, also sdbrhit one copy of this form within 30 days of
13b.Disinfection type: hn. Amount: completion of well construction.to thel county health department of the county
where constructed.
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I I