GW1-2021-01989_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.WWe�ll�contractor Information:
14.WATER ZONES t
FROM TO DESC7tIP1'(ON '
Well Contractor Name R R /v /
4341 iA r R h
NC welt Contractor Certification Number 15.OUTER CASING for mahi-used well+ ORLIKER tfa hie
FROM TO DiAAi TER 1 7MCKNESS MATERIAL
/ 1
PoA+ -� O% fL I
im 6a11M r'
Colo any Name 16.INNER CASING OR TUBING . thermal desW4W
2.Well Construction Permit#33 2 23(i FROM TO DtAMLM THICKNESS MATERIAL
List all applicable well construction permits Q.e.UIC.County,State,Variance,etc.) R D m.
3.Well Use(check well use): ft. fL
IN
ter Supply Well: 17.SCREEN
PP Y FROM TO DIAINhTBR SLOT SIZE THICKNESS MATERIAL
gricultural [3Municipal/Public 0 & ft is
eothermal(Heating/Cooling Supply) okesidential Water Supply(single) ft, fL in.
Industrial/Commercial Residential Water Supply(shared) IS.GROUT
Irrigation FROM TO MATERIAL EMPLACE ftw METHOD&AMoumr
n-Water Supply Well: U ft � ft p
onitoring Recovery ft. ft.
ection Well: fa R.
quifer Recharge Groundwater Remcdiation
19.SAND/GRAVEL PACK f s lieible
quifer Storage and Recovery [)Salinity Barrier FROM TO MATEMAL EMPLACEME ff MUiHOD
quiferTest [3StormwaterDrainage ft ftxperimental Technology Subsidence Control ft. ft.
eothermal(Closed Loop) 07f acer 20.DRILLING LOG attach additional'sheets ifneeesaaeothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DFSCRH?(ON color,hardness,volt/rock tym gnin acre,etc
Q, rt ft-
4.Date Well(s)Completed: 1 �Z Well ID# 0 ft- 5 fQ e, c, ° pd
/ ft W ft "
Sa.Well Location: �`•'
aru MPSon ft 't• MAY 2 7 2021
Fcility/Owner Name n I nn '' Facility IDM(ifopplicable) h- ft.
ap
_ 5, �1 he. 1`�Id4 a Ind, �ebU�O ft. ft i-i vCtti 3t. a
Physical Address,City,and Zip ft ft
n 21.REMARKS
County Parcel Identification No.(PiN) IU404 ve
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latAong is sufficient) 22,Certificati C
6.Is(are)the well(s)dPermonent or Temporary Signature ofCcrn c oll onanctor Date
By signing this form,I hereby cen#y, that the well(j)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or No with ISA NCAC 02C.0100 or ISA NCAC 02C.0100 Wdl Construction Standards and that a
If this Is a repair,fill out known well cansrnrction information and explain the nature of the COPY of this record has been provided to the well owner.
repair under 921 remarks secilon or an the back of this form.
23.Site diagram or additional well derails:
8.For Geoprobe/DPT 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-I is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
�S_ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (f0 24a. For All Wells: Submit this firm within 30 days of completion of well
For multiple wells list all depths/fdfferent(example-3@2200-and 2 100') construction to the following:
(
10.Static water level below top of casing: /v0 (ft) Division of Water Resources,information Processing Unit,
If water level Is above casing;use +/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: a� ry above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following: i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: n/ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test 9 l�r/l� 24c.For Water Sugp!X&IniecdonffWells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount �C1 completion of well construction to the county health department of the county
where constructed.
Form G W-1 NoM Carolina Department of Environmental Quality-Division of water Resources Revised 2-22-2016