GW1-2021-07052_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: i
` 14.WATER ZONES 1
Well Contractor Name FROM TO DESCRIPTION
n ft. Vlf n fL
Mcw
NC Well Contractor Certification Number 15.OUTER CASING foi-Iti-cases wells OR LINER if a licable
1 1 �(` 0 1 f � l FROM TO DIAMETER THICKNESS MATERIAL
1 1 fL ft. in.
Company Name V
16.INNER CASING OR TUBING eolherntal closed-loop)
2.Well Construction Permit#: 1 `o��-Y FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,State, Variance,etc.) ft. ft. in.
i
3.Well Use(check well use): ft. it. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_.)Agricultural I to
`l^ ft. �^� ft. O, (� w .+�
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. t[. in. r
t�
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. o tt. f dIb ; v
Monitoring Recovery ft. ft. 1i.�C
Injection Well:
_ Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable
Aquifer Storage and Recovery r.IISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:)Aquifer Test DStonnwater Drainage Do it. ft.
Experimental TechnologyISubsidence Control ft. ft.
i
Geothermal(Closed Loop) FnITracer 20.DRILLING LOG(attach additional sheets`if necessary)
BGeothermal(Heating/Cooling Return) ]Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock a rain size,etc.)
ft. ft. .1
4.Date Well(s)Completed: t of wwell ID# ft ft.
51a.Well Location:
l
fL 1 iY. ft. C
Facility/Owner Name Facility 11D4(if applicable) Q U`aft. r f. r C
�".TIJ.J�
Phy ' al Address,City,and Zip Lot*
ft. ft.
OY� 03 oal °1��p3 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/lo'ngLLis sufficient) 22.Certification:
`l�• qgv ��� ` . (01q W r t
6.Is(are)the well(s) Eermanent or OTempbrary Signature ofCertifi Well Contractor 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: nYes or 00�o 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 nd explain the nature ofthe 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 ifdiffereni(example-3@2010',and 2@100') construction to the following:
10.Static water level below top of casing: 1�{' (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
aa t�t� y above, also submit one copy ofthis form within 30 days of completion of well
12.Well construction method: 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) V Method of test: rmn 24c. For Water Supply&InieIction 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: Amount: ' 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