GW1-2021-06612_Well Construction - GW1_20211007

WELL CONSTRUCTION RECORD GW- � TIN For Internal Use Only:
1.Well Contractor Guam
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OM TO DESCRIPTION
Well Contractor Name
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NC Well Contractor Certification Number Q ;TS:AUFER.CASING tor:mulhcase8tvells OR1dNER tfa"heabte S
£ " (' E �' FROM TO DIAMETER s THICKNESS MATERIAL
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Company Name
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2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1G County.State, Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
W ter Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural []Municipal/Pubiic ft. ft. in.
Geothermal(Heating/Cooling Supply) E31kesidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) ,IS:;GROUT
Irri atien FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
049:SA7VDlGRAVEL PACIz'_tf•a `ticatile .._ "
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATEMI, I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20.-DRIL'LING1 OG attach'additionat3Leets;dnecessa
Geothermal(Heating/Cooling Return) Mother(explain under#21 Remarks) FROM
ft. TO ft. DESCRIPTION color,hardness,soil/rock type, rain size,etc.
9 5 �C► ft. ft.
4.Date Well(s)Completed: Well ID#
5a.Well Location:
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Facility//Owneer�Namjee Facility ID#(if applicable)
27 14 V Rbi p�nr 'Rn /y���,yi J I-) ft. ft.
Physical Address,City,a d Zip
J21evel ar& 21 REMARKS
County YLI Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: /
N W —15—�oa/
6.Is(are)the well(s) ermanent or OTemporary Signature ofCer tfied Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)-const_rncted in accordance
7.Is this a repair to an existing well: E)Yes or dNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
//7his is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: L SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: l0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi(ferent(example-3C100'and 2@1001 construction to the following:
n/
10.Static water level below top of casing: in J (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:�Sp (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
�rt 1 above, also submit one copy of thism'fot within 30 days of completion of well
12.Well construction method: l 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 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) (0040m, Method of test: 24c.For Water Supply&Injection 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: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016