GW1-2021-03063_Well Construction - GW1_20210624

WELL CONSTRUCTION RECORD(GW-1) For internal Use only
1.QWell Contractor Information:
I e N 14.WATER ZONES I
Well ArKarne TO DFSCRWMN
35741 l�+0 Vio I e
IL
NC Wen Contractor Certification Numbs
15.OUTER CASING OW malffrrasa wells OR LII�R eta bier
FROM TO I mmuAL
t��h S�eu "5 L(.} 1 l �r� ��►•�q 1►1 G • 1 t n. 3 q
�i y Nam _ I&UDIER CASING OR TUBING thermal leaed-loo
2.Well Construction Permit#: 3s'1 a5 3 FROM TD DIAhWTM I MCKM SS4 I MATIMUL
List all applicable wa eons&udfon permits rr.e.UIC Cownty,S7mt Variance era) tt It in
3.Well use(ebeek well use):
Water SupplyWell: t7.scREEN
FROM TO D1AMElM SLOT s>ZE 2HICENFSS MATERIAL
3AVicuftural �IvhmicipaVPublic U a tt
Geothermal(Heatt*Cooling Supply) [2)Resideatial Water Supply(swgle) M
Residential Water Supply(shared) 1&GROUT I:
on FROM I TO MATERIAL EM[LACEMEW METHOD&AMOWff
Non-Water Supply Well: 0
tt ft-
-Monitoring QRecovery tt �O it
Injection wen:
ft tt
Recharge DGmundwater Remediation
l9:SAPID/GRAVEL PACK a bteIIJ
Eal
Storage and Recovery [)Saltn4 Barrier FROM TO MAIERW. METHOD
Test [)StormvrAcr Drainage ieenW Technology Subsidence Control �mal(Closed Loop) DTraeer20.DRII.LING LOG amen additional sheets ifneuass .
m (HeatinglCooling Return) Other(explain under#21 Remadcs) FROM To DESCRUMON-Tor, seWnuk IMw,Vain Aw.eta
O it � -Q.GQ- �-l[-�.
a.Date weII(s)completes: b 1(6 aD a well iD# 3 S'1%Z S 3 1D fL tL `1 r r
5a.Well Location: Lto
Facrlily/ Name Fa((c��ilityII)0(ifapplicable) B' H'
11)"i rtx9�ii�e 1�cQ. 'd IJ C, ), S R tt
Fhys cal Address,City,and Zip ft. tt
2L REMARKS
Copy Parcelldenti5tationNo."4) Inf i ation Processing Unit
5b.Latitude and longitude in degmes/minutes/seconds or decimal degrees: DItUR SeCi on
(if well field,one latdong is sufficient) 22.Certification:
fib- N 7g. 4� �b5 W
6.b(are)the well(6)60Permanent or DTemporary SipaturefCNfifiedWe1lCbntracw 1
By signing this form.I hereby certify that the weft(s)was(were)eonsYnrded.in accordwee
7.Is this a repair to an existing well: OYes or fflNo with 15ANCAC 02C.0100 or 15ANCAC 02C.0200 WeU Construction Srarukr ds and that a
Ifilus is a repair,fff out known weU consbuction igformation and explabr the nmwm ofthe copy of this record has been provided to the well ownw.
repair wider#21 remarks section or an the back of thisform.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the ba k 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 I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �J (R-) 249k. For All Wells: Submit this form within 30 days of completion of well
For mw1hple wells fist aU depths if dir"rat(exmnple-3(a)200'and 2@1M construction to the following:
10.Static water level below bop of casing: 30 04 Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Man Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
�� abdPe'also submit one copy of thisI form within 30 days of completion of well
12 Well construction method: {ZO 1
(Le-auga,rotary,cable,direpu�etc.) I construction to the following
et I! i
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
m)
13a.Yield(gp Method of test: % 24c.For Water Snooty&Injection Wells: In addition to sending the form to
pp `. the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 0Gji 4 Pi Amount: bZ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Fmvi onmental Quality-Division of Water Resources Revised 2-22 2016