GW1-2021-07556_Well Construction - GW1_20210903

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WELL CONSTRUCTION RECORID -1 For Internal Use Only:
1.Well Contractor Information:
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WellContraUorName TO DESCRIPTil1H ;
NC Well Contractor Certification Number �
V\�Q`�,�j O w1IS�' IS OUTER:CASING for'mnld;&iidlvelli ORLWER(if'"
V FROM TO D ERI THiCKNESS MATERIAL.
Company Name `A&EWERa'Z ft fL to.
2.Well Construction Permit#: t�/ 1 Q�(� _ FROM -I
T LNG OR.TI IAM �,ER e I TMCLQVEss , '.:MATER1pL :J;
List all applicable well construction permits(i e.UIC County.State,Variance,eta) ft. ft. in.
3.Well Use(check well use): fL fL In.
Water Supply Well: 317. ::a•i
FROM TO I DL"WFER I SLOTS IZE TmCKNESS YMATERiAL
Agricultural cipal)Public U & is
Geothermal(Heating/Cooling Supply) Ofiesidential Water Supply(single) tt ft- to
Industrial/Commercial Residential Water Supply(shared) u nn •tom .. _
.s1t1:GRAUT<c27S-'.f�• �•;it Y �:1�.::=�..',:: f .n v.It.- N.4:
.140gation FROM ITO MATERiAL f, EMPLACEMENT METHOD&AMOUNT.
Non-Water Supply Well: 2 c -b & p C
Monitoring Recovery R fL
Injection Well:
3. Aquifer Recharge DGroundwater Remediation R fL
A uifer Sto ,119.'SANDIGRAVEI:PAcK a" Tie6b1E < :'.;;s's;:::?`;+:r, i%`•=_``;::'" ;'-r
Q rage and Recovery OSalinityBarrier FROM TO MATERIAL EMPLACEMENT MEMO D
AquiferTest r3StormwaterDrainage R iL
Experimental Technology Subsidence Control ft. tt
Geothermal(Closed Loop) [3Tracer ;20.'DRELLiNGLOG eftiiihaddffioualaheets`ifneoi3iii'
Geothermal(Heating(Cooling Re ) Other(explain under#21 Remarks FROM TO DESCRIPTION�color bent soWrock ,seta
of, . F oft. roa l •or
4.Date Well(s)Completed: / Zi Well lD# ft. 7 7 4-11- g n
5a.Well Location: t tef
ft. O ft. ullf
�-t-,N&4-- fL � ft.
Facility/OwnerName /� _ Facility WN(ifapplicable) ( wit. � ft.
77.3 tC Q.'7 t�P J;l t l/b' -yy_ fL fL
Physical tAddress,City,and Zip & ft.
--
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one la on9 is sufficient) Q1k yy��' `` (� 22.C 't lion:
6.Ware)the weli(s) ermauent or Temporary Signatfire ofCertified Welt Contractor Datc .
By stgning this form,I hereby certify that the ivell(s)%vas(were)constructed in accordance
7.Is this a repair to an existing well: .3Yes or 0 o %vith ISA WCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out kno%vn well construction Wormadon and eTlaln the nature of the copy ofthis record har been provided to the well o%vner.
repair under#2I remarks section or on the back'ofthisferm.
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 I GW-1 is needed Indicate TOTAL NUMBER of wells v .•COnstruction details. You may also attach additional pages if necessary.
drilled
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_ 00 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wdLr lint all depths#Idlfferent(example-3®200'and 2@1005 construction to the following:
10.Static water level below top of casing: (FL) Division of Water Resources,Information Processing Unit,
Ifwater level&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
A.r con&Z/ above,also submit one copy of this form within 30 days of completion of well
(L.Well construction method:e.auger,rotary,cable,direct pasty etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) Method of test: a it ,t 3 'L 24c.For Water Suppiv&Infection Wells: In addition to sending the form to
a / the address(es) above, also submit one copy.of.this form within 30 days of
13b.Disinfection type: Amount: `4 completion of well construction to the county health department of the county
where constructed
Form GW-1 North Carolina Department of Eavironmental Quality-Division of Water Resources, Revised 2 22 2016