GW1-2021-07012_Well Construction - GW1_20211025

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information-
l_„ t Y' 14.WATER ZONES I` 1
a FROM TO DESCRIPTION
Well Cop[rac[or Na
3a ft.
NC Well Contractor Certification Number
'V� � - 15.OUTER CASING for '-eased OR LINER:if applicable)
8 FROM ft.
TO tt DIAMETER in THICKNESS MATERIAL
Company Name (� ' J � ��
16.INNER CASING OR TUBING m e6theral closed-loop)
2.Well Construction Permit#: "� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.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 THICKNESS MATERIAL
:.)Agricultural DMunicipal/Public ft. ft. in.
__I Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/commercial RResidential Water Supply(shared)
R ---
18.GOUT."
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ,,r
rm in
Monitoring ORecovery it. J� ft. X.•
Injection Well:
ft. ft.
_ Aquifer Recharge DGroundwater Remediation _
19.SAND/GRAVEL PACK if applicable
Aquifer Storage and Recovery �ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:)Aquifer Test 01 Stormwater Drainage ft. ft.
Experimental Technology []I Subsidence Control
Geothermal(Closed Loop) r.lITracer 20.DRILLING LOG(attach additional sheets if nccessa
_I Geothermal(Heating/Cooling Return) 01Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft. ft
4.Date Well(s)Completed: (� (G� Well ID# ft. f I ft. b '
ft. ft. I Ja
Sa.Well Location:
ft. In ft. i
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
1-11 W^it
Physical Address,City,and Zip
21.
� / �.J� 1 IV W3 REMARKS
County Parcel Identification No.(PIN) I(�f0[Ci'3�IOt1 secilon
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
) � .H 19 N -70° �35,SCI 5- W •
S tom[ �=". VV i�� ►1- 19
6.Is(are)the well(s) Permanent or OTemporary Signature of Cer ied Well Contra i�r Date
By signing thi form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: EIYes or No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information a 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 i£necessary.
drilled: 2� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierew(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
11.Borehole diameter: L42 (in.) 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: construction to the following: I
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) Method of test: Ov rnpi aa 24c.For Water Supply Bt Infection Wells: 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: Yi Amount: t 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