GW1-2021-03915_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: 10�
F`(G Gr� a,•.� - 14.WATER ZONES
•is,,3 �� 41FR�Q TO DESCRIPTION
Well Contractor Name 2�Z8'7��-� , �, ft fzll _.,;�C ft ft
NC Well Contractor Certification Number + rA $ �
t ',_ C,' •r15.OUTER CASING for multi-cased wells.OR LINER 1f a licablc
0� ),pfJ / �'P/ �� _,�nj',t �✓J FROM TO DIAMETER THICKNESS MATERIAL
5 (moo rJf G <j\•' �� ft /5 ft in. A?G
Company Name ��' v
��� ��`� _ / 16.INNER CASING OR TUBIN cothermal dosed-loop)
2.Well Construction Permit#: 7 ( FROM TO DIAMETER THICKNESS MATERLIL
List all applicable well construction permits ri.e.UIC County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THIC ESS MATERIAL
Agricultural Muni blic /S ft S ft in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) v ft, ft in, ( !�
D,Industrial/Commercial Residential Water Supply(shared)
18.GROUT -
_ Irri atlon FROM TO MATERIAL EMPLACEMENT MJLTHOD&AMOUNT
Non-Water Supply Well: 0 ft ft. I&/hV
Monitoring Recovery ft ft
Injection Well:
ft It.
Aquifer Recharge []Groundwater Remediation
Aquifer Storage and Recovery 19.SAND/GRAVEL PACK if applicable)
A q g ry E)Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
_ Aquifer Test [3Stormwater Drainage ft ft
Experimental Technology Subsidence Control It. ft
_j Geothermal(Closed Loop) Tracer .•.20.DRILLING LOG lattach additional sheets if necessary) -
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) I
FROM TO DESCRIPTION color,hardness,wir/rock type,grain slze etc
/1 ft 16- ft S 6 /Q`
4.Date Well(s)Completed: r Well ID# s ft O ft SI C�a ->'
5af.�W�elll Location: ) 1 / lQ R' 2 tt
t'ISM i'IS ft �/pl� �ifi��e '"1tP• /:„Y �y�
Falcility/Owner Name ¢'FFacii itty ID#(if applicable)
li ) �S ft Gi/S ft fl
V ar r`ct. l �Y ! ft / ft
Physical Iddess,City,and Zip IF
1� I ,{�� ft O ft' S� Q h q kck)• —
t 1N (W `Z)10- 003�i 21.REMARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one la sufficient)
t/long is sucient) 22.Certification:
�t
h W-• 0 N �(_ �23 W ✓
_ 6 � z
6.Is(are)the well(s)E)Permanent or Temporary Signature ofCertifi6 ell Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or o with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out latown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional 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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a200'and 2@100) Construction to the following:
1 i
10.Static water level below top of casing: / (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+^ i 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 24b.For Infection 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: �CrV
construction to the following: f
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: / 0 1636 Mail Service;Center,Raleigh,NC 27699-1636
13a.Yield(gpm)_30 Method of test: ' �—/F� 24c.For Water Supply&Inieetion Wells: In addition to sending the form to
I the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1 Amount: completion of well construction�to!the county health department of the county
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