GW1-2021-05932_Well Construction - GW1_20211115

WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only: y•_
1.Well Corriere f lion:
O � 14:WATER ZONES
Well ConaLtor Name [FR'
M TO DESCRIPIlON
76�� fL �
v R ft.
NC WeUConnaetorCertiS Number OUTER.CASING. for:'andfkawdWelk'ORLINER.tfOM lTO DIAMETER 1HICIINESS MATECompany Name ft- ( 7v 1L��Sr'� / -1fNN]EMN a:SIl�G OR.TUBING:
2.Well Construction Permit#: 4 FROM pi
DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(.e.UIC.County,State,Variance,etc.) ft in.
3.Weft Use(check well use): is
kAgricultural
ter Supply Well: '41,SCREEN` . ....
FROM TO DIAMETER SLOTSIZE THECWVESS MATERIAL
®M blic 0 & eft is ��C
eothermal(Heating/Cooling Supply) idential Water Supply(single) & m.
dustrial/Commercial QResidential Water Supply(shared)
. �.GRO[ri
ri ion FROM TO MATERIAL EMPIA ENT METHOD&AMOUNT
Non-Water Supply Well: R & CCLtC/` p vn d
Monitoring Recovery R &
Injection Wen: & R
Aquifer Recharge DGroundwaW Remediation
19:.SAN1D/GRA�Et:°pAEg ..
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL 1 EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage & ft.
Experimental Technology Subsidence Control f< &
Geothermal(Closed Loop) Tracer 2b DRIId ING':LOG.awehadditienol a5eess.if .
Geothermal eatin Cool' Rerun Other( lain under#21 Remarks FROM TO D N cvtor na.doer,soilirock etc
O &
4.Date Well(s)Completed: t3/ Well ID# 0 v &
5a We lion: & %
�` de% Me & & y r /
Facr7ity/ Name/ / if M4(ifapplicable) ft f<
Physical City,and Zap f ft fL DINR SECTION
,� 2LREMiARRS \I P1RA J
Copy Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Wong is sufficient)
22.Certification:
6.Is(are)the wdl(s) ermanent or Tempo;-o
Si p==ofCertified Well Contractor Date
By signing this form,1 hereby certify ihat the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes O[ with 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown weft construction mformationanderplaw the nature of the -PY ofthis record has been provided to the well owner.
repair under 921 remarAs 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 i GW-1 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: _ r�©� (fL) 24a. For All Welts: Submit this form within 30 days of completion of well
For multiple wells list all depths(different(ermnple-3Qa 200'and 2(a)1003 construction to the following:
10.Static water level below top of casing: �0 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use..+^ 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 010 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: tOct) above,also submit one copy of this form within 30 days•of completion of well
(i.e.auger,rotary,cable,direct push, r construction to the following:
Division of Water Resources,'Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man Service Center,Raleigh,NC 27699-1636
132.Yield(gpm) Method of test x y P 24c.For Water Supply&Iniectjon Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: T if Amount O completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Deparmtent of Environmental Quality-Division of Water Resomc�s Revised 2-22-2016
I