GW1-2021-01856_Well Construction - GW1_20210503

WELL CONSTRUCTION RECORD(GW-1) For Internal Use only:
i
1.Well Contractor Information:
` r
ex S 12 14.WATER ZONES
Well
FROM TO DESLR MON
dare
36 n- 36S ft
NC Well
1`Contractor Cecoifiwlion Number i M OUTER CASING [or multi cased OR LINER da ble
\Vl r J' FROM TO !T.�]
In
Company Name Y
t�Q 16.1NNER CASING OR TUBING tteerma{dosed-too
2.Well Construction Permit#: 3 V O ( mom TO DIAAWM I TIIICIQMEss MATMAL
List all applicable wa ewwmction permits(e.UIC Coswy,State.Vark"M etc..) ft. It. iv
i
3.Well Use(check well use): ft' m
Water Supply Well: 17.SCREEN
FROM TO D1AME1ER', SLOT SII.E MATERIAL
Agricultural OMunicipal/PubL° 0 It. >9t. in.'
Geothermal(HeatmWCooling Supply) WResidential water supply(single) IL it. iw.
IndushiaUComme.W QResidential Water supply(shared) 1&GROUT
on FROM TO MATERIAL EMPLAI�METHOD&AMOIIHIT
Non-Water Supply Well: O tt 3 it u,\ ek
Monitoring ORecovery & o ft- 1
Injection Well: tL &
Recharge []Groundwabar Remediation
19.SANDJGRAVEI.PACK rf a ble
3AquilbrStorageandRecovery DSalinily Barrier FROM TO MATERIAL EMPLACEMEPPl METHOD
3Aquifer Test DStormwater Drainage ft. ft.
EVerimental Technology Dsubsidence Control ft
i
Geothermal(Closed Loop) Tracer 2&DRUJ MG LOG attach additional sheets itneceasa
rj
Geothermal(Heating/C.1tog Return) Other(explain under#21 Remarks) FROM To DEseR>PIroN color etc
ft. A .tL
4.Date Well(s)Completed: _ Well ID# ?j0 ft- ft ro
a 3 n' star z d r
SR.Well Location:
mar►A AdCo c-k 93 S-os-' L rA
Facility/Owner Name FaeiUy00(ifapplicable) ft. & c•'"'
S^�S W t6 r t!; ft. iqlputl
Physical Address.City; d Zip n IL
11 — 2L REMARKS
County parcel Identification No.
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees:
(if well field,one lat/Iong is sufficient) 22.Certification:
-7�6' 1q `f5l N 74s. 39
6.Is(are)the well(s)wPermanent or QTemporary Signature of t;5cd well tractor Date
By signing this form,1 hereby certify that the weR(a.)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or Ca,No with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Weil Construction Standards and that a
If this is a repair,ftU out known well consbrtdion information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under 921 remants 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
construction,only 1 GW-1 is needed indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:. SUBMITTAL INSTRUCTIONS j
9.Total well depth below land surface: 510.5 ( ) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple we&list all depths ifdifferent(=ample-3@2001and 2Qa 100) construction to the fallowing:
10.Static water level below top of casing: 30 0L) Division of Water Resources,Information Processing Unit,
Ifwater level is above rasing,use"4" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:_ _(in.) 24b.For Injection Wells: In addition to sending the form to the address in 248
12 Well construction method: l41 4� � above,also submit one copy of this form within 30 days of completion of well
construction to the following
(i-e-anger,rotary,cable,direct push,etc-)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: t 24.For Water SnDDIY&lniection Wells: In addition to sending the form to
LL the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ( Le-- Amount: 5 O Z completion of well construction to the county health department of the county
where constructed.
TwrmC.W-1 North Carolina Department of Environmental Quality-Division of water Resources Revised 2-22-2016