GW1-2021-07475_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well/Contractor Information:
OOd y Allen 514+ 14.WATER ZONES
Well Colitractar Name FROM TO DESCRIPTION
�1395-� I o IL XI ft- 2 &PM
ttto ", PeA
NC Well Contractor Certification Number 15.OUTER CASING for multi Med webs OR LINER da lix e
Qob y'S W e U D r;I�r rla FROM zo DIAA>E1ER THICKNESSMATERIAL
Company Name 0 n (03 fL (�t� 'u' I Stall 24 pue,
qn 16.INNER CASING OR TUBING(geothermal dosed4000i
2.Well Construction Permit* d ioj o 9 (Q FROM TO DIAMETER TEMC ENM MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc) M IL in.
3.Well Use(check well use): ft. M 'II
Water Supply Well: 17.SCREEN
FROM TO I DIAMETER SLOT SITE I TMC ENFS5 IMATERIAL
❑Agricultural ❑Municipal)Public IL R m
❑Geothermal(Heating/Cooling Supply) MW.,idential Water Supply(single)
!ti ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT
❑Irri tion ' ❑Wells>100,000GPD FROM TO MATERIAL EMPLAOl11ENTMETBOD&AMOUNT
Non-Water Supply Well: M ft. (3[tf '►`
( (;M: S rpuIr
❑Monitoring ❑Recovery fL fL
Injection Well:
tr.
❑Aquifer Recharge ❑Groundwater Remediation ft.
19.SAND/GRAVEL PACK if a licahte
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO i MATERIAL EDn'LACEMENTME1HOD
[]Aquifer Test ❑Stormwater Drainage fL I B
❑Experimental Technology ❑Subsidence Control It I ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothemral(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soW—k qM grain. she.etc.)
a m 9
4.Date Well(s)Completed: 3-9-,202 J Well ID 7# 4 rc � G t�C
Sa.Well Location: I.20 de 1)iGG
bmam ze4ta&;A 17eemer 1121 n' .280 fL i}
Facility/Owner N me Facility ID#(if applicable) P.So R' 2 1 , fC V iL�
_t,J Dtowo Ford Z9I f 340 fL ni
Physical Address,City,and Zip IL ft. NOV 1 92021
/'st e I r - 31 , 21.REbL RKR
County ParwiIIdentifiicationN(o (P o
r ()1lJ>aCJn,^�CCIR� IIA"
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W
eLlw
6.Is(are)the well(s): @Permanent or ❑Temporary Signature ciCtertified Well Contractor Dale
By signing thisform,I hereby c-n*—that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or DNo I M NCAC 02C.0100 or 1 SA NCAC 02C.0200 Wel!Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner
repair under§21 remarks section or on the back ofthis form.
23.Site diagram or additionsl 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'm Remarks Box).You may also attach additional pages if necessary.
drilled:
t 24.SUBMTITAL INSTRUCTIONS
9.Total well depth below land surface:
(1L) Submit this GW-1 within 30 days of well completion r the
For multiple we/is list all depths rjdijjeroa(example-3Q200'and 2Qa 100) ys p per following:
10.Static water level below top of casing: yD, (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing use
l/"+" Information Processing Unit,1617MSC,Raleigh,NC 27699-1617
11.Borehole diameter: tp�y ftn.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
n Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: A i t- RA my 24c.For Water Suaaly and Open-Loop Geothermal Return Wells:Copy to the
(i.e auger,rotary,cahle,direct push,etc.) I county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells prodgglagi over 100 000 GPD:Copy to DWR,CCPCUA
13s_Yie_I (gpm) �f7 Method of test: A i r
Permit Program,1611 MSC,Raleigh,NC 276 -1611
r
13b.Disinfection type: YH Amount: 9 D2
Form GW-1 North Carolina Department ofEavwnmental Quality-Division of Water Resources Revised 6-6-2018