GW1-2021-00670_Well Construction - GW1_20211222

Mks':• -- .:- - -:. - ._.. .., 1 r'l1�:
INSTRUCTION RECORD(GW4) For Use Only:
Internal
'tractor Information: -
14.ayATER ZONES
FROM I TO I DESCRIPTION
rAnti-actor Name [t• ® ft.
el),.KL ft. ft.
>:SIC Well Contractor Certification Number M7GlJT.ER CASING for multi-cased wells OR_ l?gE'R:rfst.olicable
/I FROM TO DIAMETER
Well
W► THICKNESS MATERIAL
"� T •� 1 t•. (b. ft. ft. : in. Is
o.
` Company Name 1 16. R CASING OR TUBING ebtbertnal dosedaoo
2.Well Construction Permit Aw b q bJ d` - �P v ' I FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable+uc ll eonsn•eiction permits(i.e.UIC.County.State. Varia;z&,etc.) ft. in.
ft. ft. in
3.Weil Use(check well use):
17.SCREEN
Water Supply Well: FROM TO D1AatETER 1 SLOT SIZE THICKNESS I MATERIAL
Agricultural .unicipal/Public ft. ft.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. fL in.
i
Industrial/Commercial OResidential Water Supply(shared) 48.GROUT
Ir[I anon FROM TO MAT' [AL EMPLACEMENT METHOD THOD&AMOUNT
Non-Water Supply Well: O yk in It
Monitoring ,:Recovery ft ft.
1niection Well: ft. ft.
Aquifer Recharge 3Groundwater Remediation
$9.SAtN4`iD/GRANTI,PACK R—OPWAhle
Aquifer Storage and Recovery OSalinity,Barrier FROM i TO MATERIAL. Er/fr* CEMENT METHOD
Aquifer Test ostormwater Drainage ft.
Experimental Technology oSubsidence Control tt ft.
Geothermal(Closed Loop) OTracer4 1}R7ttltat]G.YartetrCailditf6nnlsheetsStieressst
fs RROVi TO i DFSCRtVnON color,hardacss.sot frock
Geothermal(Heating/CoolingReturn) Other:(explain under.ill Remarks) ft it.
4.Date Well(s)Completed:�J _ Well ID# V) Q n ft. a n
5 ft. !7
Sa.Well Location: ( a
�try
h a—
Facility/Own r Name Facility ID#(if applicable)
ft. ft.
Physical Address,City,and Zip
Il (� �� f 21.1lEiVtARKS
5 d i I
��.1�"vr�tiill�ltri.r1+.1 �ti11`•i�i , ::
County Pared Identification No.(PIN)
5b.Latitude and longitude in degreesllninutes/seconds or decimal degrees:
(ifwcll field,one latnong is sufficient) 23»Certifi ation:
6.Is(are)the wells) ermanent or OTemporary
Stgtsat c of ificd WellVontr4tor
g signing this form,1 herehy cent fi that the r nll(s)xvr(Inrte✓em 4micied in accordance
7.Is this a repair to an existing well: [3Yes or NO ++I�15A.NCAC 01C.0100 or 15A NCAC 01C.0100 Welt Gotts�xc#imtStandards and that a
1f[his is a repair,fill out known well eonstrucfion infomHtttotiartd explain the nature ojthe rrraf this record has been provided to the well owner.
repair under 421 remarks section or on the back ofthis fora. 23 Site diagram or additional well details:
R.Far Geoprobe/DPT or Closed-Loop Geothermal Wells having lire same Y ema may use the back of this page to provide additiot3al 11 iitt details or well
R.of wells
consiruction
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBE details: You may also attach additional p ifaceessary
drilled: 1 _ / SUBMITTAL INSTRUCTIONS
O a
9.Total well depth below land surface: t (ft-) 24 . For All Wells: 'Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a:200'and 2(it-100') codstrtiction to the following:
to Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
l uuttrlevet is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 21699-1617
11.:Borehole diameter: (in.) 14b.For Infection Wells: In addition to sending the form to the address in 24a
axe.also submit one copy of this form within 30 day.of completion of well
12.Well construction method: Q I 40,rl — zzcsm-tion to the following:
(i.e.auger,rotary,cable,direct push,etc.)
tision of Water Resources,Underground Infection Control.Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
b W
13a.Yield(gpm) Method of test: 2 .-Flit Water SuuDly&Iniection!Wells: In addition to:sending the form to
i Address(cs) above, also submit one copy of this form within 30 days of
13b.Disinfection type: __ Amount: ''on of well construction to the county health department of the county
r�ttsmLcted.
1,h.Division of Water Resources Revised 2-22-2016
�.... ttinrih ramlina Deoartment of Enviro .y