GW1-2021-07010_Well Construction - GW1_20211025

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I
1.Well Contractor Information: (�
I� (�Y 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION — '^
ft. J ft.
NC Well Contra r Certi nation Number -
15.OUTER CASING fm multi-cased wells OR LINER if n licablc
�C FROM TO DIAMETER TffiCKNESS 9 MATERIAL
J ` v1 1lllV , ft. ft. in. a_
Company Name I�•
16,INNER CASING OR TUBING&bthern al closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER LTHICKNFSS 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 Municipal/Public ea ft. 3 it. nn. O\ , 1
Geothermal(Heating/Cooling Supply) residential Water Supply(single) in, I
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD
.,&AMOUNT
Non-Water Supply Well: O ft. a ft. n t}v 3 CRa
Monitoring Recovery ft. ft. 5� Ib P
Injection Well:
ft. ft.
_ Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if,applicablc
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:)Aquifer Test 0 Stonnwater Drainage
Experimental Technology F.7ISubsidence Control
BGeothermal(Closed Loop) rlITracer 20.DRILLING LOG(attach addition sheets if necessa
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
4.Date Well(s)Completed: Well ID# t ft. ft. 0
5a.Well Location: ft. 18 ft.
ft. ft ©lUl
Facility/Own r``N''ame Facility ID#(if applicable) a� ft. x5e M
•3^
Ph y ' al Address!City,and Zip f[. ft. CIE
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: So(j Vn
1
(if well
field,one lat/long is sufficient) uV 22.Certification: wOl'r1-'311 1" Sec 1Dn
OW N W "�� Al"T242, ONN9,
6.Is(are)the well(s) Permanent or Temporary Signature o ertified Well ntractoi Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EIYes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information/and explain the nature of the copy ojthis 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: -33 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: t (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+"/� 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: `-C (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: v� 1 construction to the following:
(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
13a.Yield(gpm) Method of test: �`71 24c.For Water Supply&Inflection Wells: In addition to sending the form to
Z/ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well constructioin 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