GW1-2021-07039_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.War
ntractor Information:
iN� 1\1 1 U D 1 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION Y
Y`J ft. ✓ ft.
NC Well Contract r Certiftication Number 15.OUTER CASING for multi-eised wells OR LINER if a licable
111 -^~� �' \ \�`\•1 ^ FROM TO DL4METER THICKNESS MATERIAL
—1 ft. 1 ft. � in. 3Ch u ��
Company Name •N/ /y�[t�� 16.INNER CASING OR TUBING 'eolhernial closed-loo
2.Well Construction Permit#: O2 /I ! 7 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e. UIC County,kaie, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN.,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
)Agricultural OMunicipal/Public in.
31 3� ft. 1 1�C,
t--)Industrial/Commercial
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
_; 1tri ation FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D
ft. ft. Q�'-YlT;'o Pus)Ir
Monitoring 13Recovery
Injection Well: ba
ft. ft.
Aquifer Recharge Groundwater Remediation JJ
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery rJISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
__.Aquifer Test IStormwater Drainage a 0 ft. ? ft. Sari Dow r
: Experimental Technology FnISubsidence Control
BGeothermal(Closed Loop) rnITracer 20.DRILLING LOG(attach additional sheets if nccessat )
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
ft, ft.
4.Date Well(s)Completed: ( Well ID#
//5��a.Well
Location: 'DaY'O U-9—� ft. ft. r CA ,
1� V•N 1 Vn ���� ��i��l 1I V" ft. �� f L � � �e°*�".��.
Facil�Owner Name CFacility
(I(D#(if applicable) ft.
NA
1 AC/ ✓� �IJwLS7 `t v ft. ft. 4�J �q1\
Physical Address,eity,and Zip
p�
n a
2obes�r IDS-D1 -"I 21.REMARKS r,'•�.r C?
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwefl►l field,one lat/long is((suufficient) P Q (� 22.Certification:
6.Is(are)the well(s) �ermanent or OTemporary Signature of Ce i ed Well Con for 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: �IYes or �No with 15A NCAC 02C.0100 or 15A NCA'C 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction it formation a/d 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-I 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:-3-5 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@100') 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"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
r
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
,`aa above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1mW\ � construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �y Method of test: �m I 24c.For Water Water Supply&Iniection Wells:Iniection Wells: In addition to sending the form to
`l the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1 1 Amount: Z completion of well construction to',the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016