GW1-2021-00319_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well�Contractor Naml
FROM TO DESCRIPTION
o,1s t0 3- 4 it. S ark d a• r"Ve
fc. S a e. CA h S I&n
NC Well Contractor Certification Number 15.OUTER'CASING for multi-cased wells OR LINER(if a licable
1� ; l 1�'�ovds we 11 Or ; I 1 1;r7� FROM ft TO DIAME;\ in R TTEEICVNNESS MATERyIAL
►
Company Name 4- 1 a 3 ft a Ise H 9 V I/ C
�/ 16.INNER CASING OR TUBING` eothernial$lose&loo
S
2.Well Construction Permit#: O o b FROM TO I 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. it. in.
'17.,SCREEN)
Water Supply Well:
t
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public in•
a'i a. t6i� 5CHH0 r7vc
! ft. ft.
a3
: Geothermal(Heating/Cooling Supply) Residential Water Supply(single) I n ft. 5�tt a in.
nustriaommercaesidential Water Supply(shared)
-- Id l/C il _�R t 18:GROUT.,,
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. U rt. e rHm de- O U r-
Monitoring O
Recovery ft. ft. (b b
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK lfa "licublc
_i Aquifer Storage and Recovery [3I Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
__:Aquifer Test IStonnwater Drainage
:)Experimental � ft' i1of }��ft'
t ' S�� tg u r'
Experimental Technology �ISubsidence Control "
_.,Geothermal(Closed Loop) FnITracer 20.DRILLING LOG(attacli additional sheets`if ri&6ssar
(Other(explain under#21 Remarks FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc)
__I Geothermal(Heating/Cooling Return) i ( p )
q� �1 © ft. ft. O 1
4.Date Well(s)Completed: -1,��c 7 0 Well ID# ft. ' ft. n 11 Cle4V
5a.Well Location: 1 ft. 13 ft. A h G u
ro.-C'J f Sob;,lap1n )/1.7ry5 L--(+ cJ y� 3 ft. I ft. n t4 oL P-A vL
Facility/Own r Name Facility ID#(if applicable) Ci ok ft. 1 ft. I—A A C/V
ft. rt.
0 5 �(Yirnln S� 5� I,S3a �yui5 C��dL 11 5-2-
Physical Address,City,and Zip ft. ft. I• _'Y_
-�AY'ncif- q& lU)—61 `b137•1D0 21.REMARKS L�
sw
County Parcel Identification No.(PIN) d-- I— ` u
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification: ^' T o- .,"ii:'�'�),•.I I
3 5° a 5", ?b N 70 ° -/� r ` VIC W r
6.Is(are)the well(s) Permanent or EITemporary Signature ofCe ed well Co❑ or Date
���((( By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EIYes or 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 of the copy of this record has been provided to the well owner.
repair under 421 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: 02 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(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: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
AI1 above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: V1 U r 0 is Y y 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) (n Method of test: LAMP 1 ACG, 24c.For Water Supply&Iniection 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016