GW1-2021-00725_Well Construction - GW1_20210322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
�1..xW,,ellll—Coontrac�tor Information:
L )`lES] l-�:^slfr'F 11� 7)� 14.WATER ZONES
FROM I TO I DMIFUT iION
Well Connector Name
Vkc C Lms n. n.
NC`Well
Coo�ntractor{Ceniifircration Number 'n 15.OUTER CASING(for mWtiaased wells)OR LINER fd a ble)
C1`Aj ]r 1 Z U1 f}�t t�1y)Q � ,� FRO( ft. TO n DUMETER to TIR�ICR M PIATERFAI.
Company Name Q 5v`
16.INNER CASING OR TUBING( anal closed-1 )
2.Well Construction Perini[#: mom To DIAAI.lBR Tetctoves.9 MATERUL
L'.rt nlf npplirnble cell ennsrnution permits lie.UIC County.Sin".Variance.I") ft. n. is
3.Well Use(check well use): ft. n. iu
Water Supply Well: F7.SCREEN
PPY FROM TO Df.+nmrER scrn sTZE TBFCR.NFss sfATEFOA[.
0Agricultural MunicipaVPublic ft. f- in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft n. is
Industrial/Commercial Residential Water Supply(shared) t&GROUT
Irrigation FROM To MATFxuL ENPI.AC 1h 7MUHOD&AMOUNT
Non-Water Supply Well: 1 n. R. O Q
Monitoring Recovery ft. fL
Injection Well: D
Aquifer Re charge QGroundwater Remedialion
19.SANDIGRAVEL PACK(Ba . ble)
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERUL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage
Experimental Technology Subsidence Control ft. I ft.
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG(attach additional sheets if )
FROM TO D ON tmbr,hardness.sdarat r. n give,etal
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) tt 3r R ^`
U
4.Date Wellls)Completed: — Well ID# tt. n. tiCO
ft. 2u D.
Sa ell Location:
n. It. \'
Fuc'n'0wner ante Facility lD#(if applicable)
ft. M
Physical Address.City.and Zip D. ft.
2L REMARKS
Count' Pamcl Identification No.(PIN)
C N'
5b.Latitude and longitude in degreestminutes/sernnds or decimal degrees:
(if well field,one Wlone is.vuffi6cat) 22.Certification: \'
fir{ N tjSi2tu�m
6.Is(are)the well(s)q A rmanent or []Temporary of Cenitied Well Contractor Date
T` gain,rh.farm.I herehr ceniif, that the rmflLN mn.s to"O ran irnered in nocnrd e",
7.Is this a repair to an existing well: ©Yes or ��{{No 'air 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Convmctlort Srnndurds and Thu,a
ffrhis is n rgmir.fill our kuoun uell cunom,nuo infomnminn rB rd a jel.m he nature if he cop`'of this record has been pnnided in the well(wner.
relwir under#21..narks secrion ur art the bark v f this firms.
23.Site diagram or additional well details:
8.For GeoprobclDPT 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: SUBMITTAL INSTRUCTIONS
9.Total well depth helow land surface: (fl-) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnrrmdriple wells tin all depths if different fecantple-3Q�2IM'emd21u/00•) construction to the following:
10.Static water level below top of®sing: C{J (ft.) Division of Water Resources,Information Processing Unit,
Iftiurer lees is a&ow caring.use " 1617 Mail Service Center,Raleigh.NC 27699-1617
11.Borehole diameter: LD (in.) 24b.For Infection Wells: In addition to sending the form to the address in'_4a
above, also submit one copy of this form within 30 days of completion of well
12.Weilconstruction method:A 1?,f construction to the following:
(i.e.auger.rotary.cable.direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) Method of tes4I' JZ 24c.For Water Suably& Infection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type:_ Amount'36 completion of well construction to the county health department of the county
where constructed.
Farm G W-1 Nonh Carolina Department of Em immmmal Quality-Division of Water Resources Revised 2-11 1016