GW1-2021-07165_Well Construction - GW1_20211006

LL VU1110IttUUIIUIM KtUUItU (UlN-1) For Internal Use Only:
1.Well Contractor Information: `
e ® 14 WATER ZONES
Well Coutra � FROM TO DESCRIPTION
a o �� 06 tio�-` ,,�,ti ft. n 17a
NJ= sigh IL
NC W Co�ractorCerfifiwtionN®ber �C� 101" 15._OUTER CASING for,muiti d tlR LINER`'if
IfCable
FROM TO DIAMETER THICKNESS MATERIAL
` ! ft. 4l in D _at
Company Nana �r���, 16:-INNER'CASING OR:Tllt3lNG' eoU�armaiciosed-loo 1
2.Well Construction Permits FROM TO DIAMETER THICKNESS MATERIAL
Lisfallapplicable well constrmetfon permits re.UIC,County,State,variance,eta) IL fL. in
3.Well Use(check well use): ft. fL In.
pIndustriallCommercial
Supply Well: 1ILSCREEN
ppy FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
0MumcV&Public fL ft- in.
hermal(Heating/Cooling Supply) deaaal Water Supply(single) fL DResden alWaterSupply(Shared) 18:GROUT
.o FROM I TO ERiAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL _ O`f' I krLRlaD Tarap Awe— Our
_ monitoring 0Recovery fl. fL SAAD G wr T.4.1
njection ell: I. fL
E
Recharge OCrrowdwa xltemediatron 19.SAND/GRAVEL PACK if l icabl =:
Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Test OStormwaterDrainage T ft
ental Technology OSubsidence Control fL
mal(ClosedLoop) Tracer 20..DRILLINGLOG attach additional sheetsifnecmr
mal(Heating/CoolingRetun _ Other( lain underb21Remarks) FROM To DESCRIPTION co�r,hard �ltraefc ns®e,Olt)
7-7-
7 ft- to D
4.Date Well(s)Completed: ! "2. Well IDS toIL ft-
5a.Well Location: ft Mn Itb
�05c Car-�'e5 ft ft
Facitiry/OwaerNmme Facility 09(inapplicable) ft fL
cV oaf ft. fL
Physical Address,City,and Zap ft. ft
--bu>�hoLrn d`�D(�l'�iL CQ 21•REMARKS
County Parcel identification No."0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Wong is sufficient) 22.Certification:N W 7-LZ/
6.ls(are)the weli(s) .T ermanent or Temporary Sipature ofCcrfffledWellContractor Date
� By signing Phis firm, i hereby certify that the wall(s)was(were)constructed in accordance
7.is this a repair to an existing well: QYes or � with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
if fhis is a repair,rill out known well construction information and explain the nature ofthe copy ofthis record hasbeen provided to the wed owner.
repair under*71 remafkssection or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells havingthe 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: I /- SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: U1�� (H) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells IAV all depfhsifdtflerent(example-3@200 mrd2Q1M construction to the fallowing.
10.Static water level below top of casing: ` (ft.) Division of Water Resources,Information Processing Unit,
lfwater/eve/is above casing.use"+" 1617 Mail Service:Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b. For infection Wells: In addition to sending the form to the address in 24a
, tt above,also submit one copy of this farm within 30 days of completion of well
12.Well cogstruction method: i-i construction to the following.
Cie.auger,rotary,cable,direct push,etc-)
Division of Water Resources;Underground Injection Control Program,
I
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �_ Method of test: 1,e 24c. For Water Supply & Injection 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: T/�' Amount: completion of well constructionto the county health department of the county
where constructed.