GW1-2021-00559_Well Construction - GW1_20211222

WEP.LL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14 WATERZONP3 I
well Contractor Name FROM TO DESCRIMON
[� �d 0 1
/®�i-7 r 14 fL ft.
NC well Contrnvtor Califiaati=NUMt e j
FROM TO r DIAMETER ITffiCKNESB MATERIAL
Company Name "
1(r.IIVNSRCASIlNG ORTUBMG(matinrindclosed-looDI
2.well Coustraction Permit : FROM TO I DIAMEM I THICKNESS I MATERIAL
LIN all applicable well conmcdon permits(le.UIC,Coway,State,Variance,etc.) ft. im
3.Well Use(checkwell use): % ft. ln.
Water Supply Wen: 17.sCRESN
Agricultural FROM D SLOT SIZE
oipaUPubli0 p ft. t't: lm
Geothermal(Heating/Cooling Supply) Wsidential Water Supply(single) rL g, im
Industrial/Commercial DResidential Water Supply(shared) Ig;GROUT
Inizadon FROM To PFNO" METHOD&AMOUW
Non-Water Supply Well: & ft.
Monitoring coveay & ft. *d.^
Itgretion Well:
.. Aquifer Recharge DGroundwaterRemediation it. fL
19.SAND/ VBL PACE
Aquifer Storage and Recovery Salinity Barricr FROM TO t MATERIAL I EMPLACEMERr METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft•
Geothermal(Closed Loop) DTracer 20.DRIIddNG IAG attachadditional sheetsif
Geothermal eatin Coolin Return Other(explainunder#21Remarks FROM To DascR>PTiox error anivlock ere
& ft.
4.Date weu(s)Completed: /2' 7 el` Well ID# Z Z, ft. tt.
5a.WeR L_emtion: ft' gig fL
t f/1 �(L p r �O•'Yt If ft. ft.
Facility] erName p Facility M9(if applicable) & ft. ' €
G f'C�t c. y�o brp fL ft. 2021
physical Address.City,and Zip
21.RF.MARas
County panel IdentificationNo.(PIN)
i
56.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one hMong is sufficient) 22��7
6.b(are)the wA(s)derm0eot or Temporary s;gaa of CeRified Well r Date
By signing this form.I hereby ratify that the we0(s)was(were)constructed in acemdmtce
7.IS this a repair/pan ez4sting well: Yes or l�To with 15ANCAC 02C A100 or 15ANCAC 02C A2W Well Consm don Standards and that a
If this is arepah;f l out brown well cons mrction infarn alon and explain the nature ofthe ropy of this retard has been provided to the well owner.
repair under#21 remarks section or on the back ofthfs farm. 23.Site diagram or additional well details:
8.For Geoprobe/1)PT 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 TOTALNUMBER ofwells construction details..Yon may also attach additional pages if necessary.
drilled: / f SUBMPITAL INSTRUCTIONS
9.Total well depth below land surface: 1 9 :/ 00 Zqa.For All Wells: Submit this form within 30 days of completion of well
For multiple wells W all depths Ifdifferent(exanple-3@200'and 2@1009 construction to the fcilowing:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If weer level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-161-1
i
11.Borehole diameter._ (lit.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: O 7�' '7 above,also submit one copy of this form within 30 days of completion of well
(Le.auge,totary,cable,ditectpt�etc-) T construction to the foDowin
Division of Water Resourcas,Underground bdecdon Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Servim Center,Raleigh,NC 2769XI636
13a.Yield(gpm) Method of test Vl/b t r'M 94�.For Water Supply&Inl"on Wells: In addition to sending the form to
,J the address(es) above, also submit one copy of this form within 30 days of
13b.Disfafecdou type: N 71 Amount: & D u^--e c4 completion of well construction to the county health department of the county
where constructed.
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Form Gw-1 North Carolina Department ofEwAmnmoatol Qlmlity-Dividon of Water Rasoumm Revised 2-22 2016
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