GW1-2021-07592_Well Construction - GW1_20210903

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WELL CONSTRUCTION RECORD(EW--1) For Internal Use Only:
1.Well Contractor information:
14.WATER ZONES
FROM TO DSSCMMON I '
ell Contmcror Name
0 "� 0 n -VG FM
33 it1- l o tL Ba fL nq
NC Well ContractarCedification Number ^ 1S.OUTER CASING for mutd-eased we OR LINER it We
FROM TO DMAUr R TMCKNESS MATERtAL
0 IL 1 412 IL is I uV
f ny Name 1 16.INNER CASING OR TUDING rmal dosed
2.Well Construction Permit#: b dd0 4u I Z FROM TO DIAMETER I THIC"ESS MATERIAL
list all appltcable uyll consinictiotr permits(ie.VIC.,Coun%State.Variance etc.) n' (L In.
3.WcU Use(check well use): ft R Its
Well: 17.SCREEN
Water Supply FROM TO I DIASIMER I SLOTSUE I TWCKNE55 I MATERIAL
Agricultural QMunicipal/Public ft. R. in.
Geothermal(Heating(Cooling Supply) 6! f Gidential Water Supply(single) ft. 4
)ndustrial/Commercial OResidential Water Supply(shared) IL GROUT
'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&A-MOUNT
Non-Water Supply Well: 0 ft. *a ft. d ��
Monitoring Recovery fL ft
Injection Well:
tt. ft.
Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PACK iFa kabte
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACE1tENT METHOD
Aquifer Test []Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) []Tracer 2M DRILLING LOG atueh addtttotmt abets Ntrecw
Geothermal Hestia Coolin Retum) Other(explain under M?t Remarks) FROM TO DESCR1PTiOIN color,hudaest soatrock tim eta
// rt. (ep a. 02&Pf"
4.Date Well(s)Completed: -2-020we11111# &0 IL led n. 67 r.
Sa.Well Location: ft. rt'
fL ft.
on
Facility/owner-Name Facility I M(ifapplicable) rt' R'
fL ft.
Physical Address,City,and Zip D' I tr
r11t
It,RErtfaRKs rrr3 gctio
County Parcel Identification No.(PiN) �O S
5b.Latitude and longitude in degreWminutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certi ieathm: �W �v/ `�y
N f t! r zo
6.Wave)the well(s)�manent or []Temparary []lure of Tied vcl Contractor Date
By signing this farm,l hereby terrify that rhejuytl(s)+ras(time)constructed in accordance
7.Is this a repair to an existing well: []Xes or ego uith I SA NCAC 02C.0100 or 1 SA A'CAC 02C.0200 iPell Construction Standards and that a
If this is a mpair,fill out kntnm uyll construction information and explain the nature gf1he rM o/dris record has been prarided to the well owner.
repair under 421 remarks section or on the back of this farm.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or L7ased-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.
drilicd: SjIR& PAL iNSTRUCTiONS
9.Total well depth below land surface: 00 24a, For All Welts: Submit this form within 30 days of completion of well
For multiple u-elk list all depths ifdiff rent(example-3@.200'and 2C100) construction to the following:
10.Static water level below top of casing: 2� A) Division of Water Resources loformation Processing unit,
!(raster level is ahme casing.use tQ"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
// � r
11.Borehole diameter. 2 (ta) 24b.For Injection Wells: In addition to sending the form to the address in 24
n l above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: At'
r R d"1 a r Z construction to the following:
(ic,auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 SUR Service Cent i,Raleigh,NC 27699-1636
13a.Yield(gpm) 1►iethod of test Pit m p 24c.For Water Spiv A Injection Wells: In addition to sending the form to
the address(es)above, also submit one copy of"this form within 30 days of
n
13b.Disinfection type:C hl)1 t Amoant•, 35 completion of well construction to the county health department of the county