GW1-2021-06496_Well Construction - GW1_20211027

WELL CONSTRUCTION RECORD (CrW-1► For Internal Use Only:
1.Well Contractor Information: ��/� ✓
�Y fo `
k� V `' `1'k s '^ l 14.WATER ZONES
Well Contractor Nam FROM TO DESCRIPTION
4ft a� ft CC�a�ck
NC Well Contractor Certification Number ft. ft.
\�, 1� ;15.OUTER CASING(for multi-cased wells OR LINERCra livabFROleY V AV ,D s Wel� D 11� G ft T�"1 fL D T in. SL� (] �VTERIAL
Company Name
( i6.INNER CASING OR TUBING eothermal elosed tnn
2.Well Construction Permit#: � I`\ 39 WSCREEN
DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i,e. UIC County,State, Variance.etc.) in.
3.Well Use(check well use): .
Water Supply Well:
IAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �iviunicipal/Public � in. Oto1 v�. Geothermal(Heating/Cooling Supply) esidential Water Supply(single) in.
Industrial/COmmercial Residential Water Supply(shared) 18.GROUT
Irri ation =TO �T'
MATERL4- EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: L ?w ��i a tFz — C>_kr
Monitoring Recovery t
Injection Well:
:)Aquifer Recharge
q arg Groundwater Remediation
_ Aquifer Storage and Recovery CK(ita livable
q g ry �ISalinityBarrier MATERIAL LACEMEIITMETHOD
Aquifer Test �Stormwater Drainage � r
Experimental Technology ®I Subsidence Control ft. ft.
Geothermal(Closed Loop) MTracer L20.DRILLING LOG(attach additional sheets if necessary)
- Geothermal(Heating/Cooling Return) rl Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock tvDe.ffrain si7^eta)
�j oft •�•� ft �u'
4.Date Well(s)Completed: Well ID# ft c�� ft.
5a. pWell Location:�Ne
r\^ P �r�/11 L Ci ft r� ft t_�.
1 J l�l' Y V��F ft. 4p ft 1"{Cll.l�
Facity/OR �AFacility IDr(if applicable) 1A ft. '20 ft Goa In 0 SJO
f
ke. NL . ft. I Ll
Physical Address,City,and Zip �G 31� fL ft.
� mherla O 21.REMARKS
County Parcel Identification No.(PRv) r
OCT
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
PrOMS
3�1 U l�N ! p f `4 Col
W fication: ` , �r+�Or�DDWReciiOn
S
6.IS(are)the well(s) Permanent or ❑1Temporary Signature o ertified Well(Contractor / Date
4' -
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or No with 15A A%CAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain;he nature of the caps of this record has been provided to the well owner.
repair under 421 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
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL L\STRUCTIONS
9.Total well depth below land surface: (fL)
For multiple wells list all depths 24a. For All Wells: Submit this form within 30 days of completion of well
ifdifferent(example-3�00'and 2@I00�
construction to the following:
If water level is above casing,use'•+"
10.Static water level below top of casing: 10 (ft) Division of water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: LY (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: mv'& above, also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) a Method of test: 24c. For Water Suonly&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
131b.Disinfection type: 11 T1 f Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1
?forth Carolina Department of Environmental Qualiy-Division of Water Resources Revised 2-22-2016