GW1-2021-02018_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
A/I is c 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3254 ft ft
fL ft.
NC Well/Contractor Certification Number _ 13.OUTER CASING for Told-cased rob ORLE4ER
1 l S't 6✓r''•• '�/ /o cl(l�! `�� FROM To MAMETER T®G7QiESS7r4!ArERIAL
ft. ft. in.
Company Name
16.INNER CASING OR 1TIBING(a"tberwal dosed-loop)
2.Well Construction Permit#: FROM To DIAMETER IrasicKNESs I MATERIAL
List all applicable well construction permits(i.e.UIC.County.State, Variance.etc.) O ft. ft. G� in.
3.Well Use(check well use): It. % in. N"
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
Agricultural QMunicipalftblic ft Lw ft m. 0f f) <,-k Ko 1.2✓G
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. I ft is
IndustriaUCommercial 0 Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD tl AMOUNT
Non-Water Supply Well- d ft- t`o it iL Cerm c.-L fe
onitoring DRecovery t t It. .� / ft. Clop U✓r�.�s �y(�/%C/°
Injection Well: ft. ft
Aqui ter Recharge Groundwater Remediation 19.SAND/GRAVEL 1'Af]C
(if spollabit)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
c
Aquifer Test DStormwater Drainage /L ft. ?p ft. `j
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed hoop) DTracer 20.DRILLING LOG aitdch additional sbeeb if am wary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM To DESCRI]MON cekr.naranew Wilrack type,graiii si etc.)
4.Date Well(s)Completed: �7�Z( Well ID# 7 6`� ft ?j ft C (C
5a.Well Location: s t ft-
PGsf►f o ti �4 �"�`�"�r tr v t ft ,,/ fL e z,
Facili /(honer Name Facility ID#(if applicable)
ft ft.
��✓{-I+ A"I K P At Z ft ft
Physical Address,City.and Zip ft ft
REMARKS v 21. Unit
FGsqus facia 4' co It1 ortri
Count Parcel Identification No.(PIN) r(0f1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lavlong is sufficient) � 22.Certif c
. d,3 ,o N !!7< GG-15:19 W
-7
6.Is(are)the well(s) permanent or DTernporary tore of Certified Well Contractor Date
� By signing this form,i hereby cert�that the-11(s)war(were)constructed in accordance
7.Is this a repair to an existing well: QYes or [3'No with ISA NCAC 02C.0100 or 15.4 NCAC 02C.0100 Well Construction Standards and that a
If this it a repair,fdl out known weft construction information and explain the nature of the copy of dais record has been provided to the*tell owner.
repair under#11 remarks section or on the hack of thic.form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Welis having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
�Z-!, t
9.Total well depth below land surface: (ft.) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple welir list all depths iij'different(example-3(a3200'and 2@lM construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use-+- .t 1617 Mail Service Center,Raleigh,NC 276"-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: A-11<C/- construction to the following:
i i.e.auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276"-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply At Infection Wells: in addition to sending the form to
the addmss(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

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