GW1-2021-07341_Well Construction - GW1_20210921

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor nformation:
C,C M S 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
A fL ft
3� 7oA ft m
NCl ell Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
f�H , I ^M A• FROM TO DIAMETER THICKNESS MATERIA
4 f� O ft. 1 y, fL I q I in
Company Name 41 16.INNER CASING OR TUBING 'eothermai closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL.
List all applicable well construction permits(i.e.UIC County.State,Variance,etc.) ft. n• in.
3.Well Use(check well use): R• R• In.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLAT SL2E THICKNESS MATERIAL
❑Agricultural ❑M tpal/Public ft. fL in.
❑Geothermal(Heating/Cooting Supply) PlResidential Water Supply(single) fL h. in,
❑Industrial/Commercial ❑Residential Water Supply(shared)
i8:GROUT t
❑Irri ation ❑Wells>100,000GPD FROM I TO MATERIAL EMPLACEM METHOD&AMOUNT
Non-Water Supply Well: ft spy/ft � eiw
❑Monitoring ❑Recovery ft. fL
Injection Well:
n. fL
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PAC K rfapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL fL
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRiLLTKG LOG attach additidnal sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM fL it u TO DESCRIPTION color,hdness,soil/rock type,grain slu,eta
4.Date Well(s)Completed: -J�-Z 1 Well ID# fL ft.
raz
:X.
Location: ft ft.
fL ft 2
Facility/Owner Name }� / Facility iD#(if applicable) fL ft
3A D I/O IV( 6� T7� •V S/ ,/t 4,J Z V fLft. l��lO� C�10(l
Physical Address,City,and Zip ft. ft
/ r�Gi 7Y716-7 21.REMARKS
County Parcel arceell iddentificcation No.(PIN) e / Owl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .4t
(if well field,one lat/long is jufficient) 22.C 'fi on:
3G /J�39'y / N W - �,,� / -z/
6.Is(are)the well(s): QYermanent or ❑Temporary Signature of Certified Well Conlr&
Date
By signing thisform,Thereby certifv that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the ivell owner.
repair under#21 remarks section or on fire 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 construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
hued' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if di ferent(example-3Q200'and 2@1003
24a. For All Welts: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: VL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter (in.) 24b.For Injection Wells:Copy io DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Ope i-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: H7% Amount: 2.(°e.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018