GW1-2021-00330_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
k-�)M \ � I 14.WATER ZONES
Well Contractor Nam FROM TO DESCRIPTION
�OSOft ft.
- 0� arom Rom,
��3- a3t. � ft. r huG4
NC Well Contractor Certifica[ion Number 15.OUTER CASING(for multi-cased well OR LINER(if a licable
FROM TO DIAMETER THICKNESSS� MATERIAL
Company Name ft
*1 ft. a . !6 in. �tAV S-�ee_L1
I 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 1-1 5q�q FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e. UIC County,Stale, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. it. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
_ Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN'
Non-Water Supply Well: ft. ft. e^ �
Monitoring Recovery ft. ft. b
Injection Well: ft. ft.
Aquifer Recharge ElGroundwater Remediation
19,SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology DSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
f� 0 ft. ft Aooso'%l
4.Date Well(s)Completed: 11 �v Well ID# ft. q ft. «�
5a.Well Location: ft. QQ ft. -+an
V V W
uD� ft. ft. 1 _\0. � '
Facility/Owner Name Facility ID#(if applicable) 30 ft. Ly'rj ft. C J`Q SCE 1 1
Onve- Rc� (U,sw, 9c ao--`I L+ ft. 1 O aft. Q
Physical Address,City, d Zip (19'�ft. d 1 oft. iL_
21.REMARKS `
County Parcel Identification No.(PIN) DEC
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) p� 22.Certification:
13A aU� N . DO� W
6.Is(are)the well(s)*Permanent or Temporary Signature of rtified Weil ntractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordaar
7.Is this a repair to an existing well: EIYes or No with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that
If this is a repair,fill out known well construction information and 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 we
construction,only I 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: C�LJ (ft-) 24a. For All Wells: Submit this form within 30 days of completion of we
For multiple wells list all depths ifdii ferew(example-3@200'and 2@100� Construction to the following:
10.Static water level below top of casing: V 1 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ii" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24
11p � p above, also submit one copy of this form within 30 days of completion of we
12.Well construction method: vl� �W� ( V1t.� 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) 30 Method of test: \ 24c. For Water Supply& Iniection Wells: In addition to sending the form t
the address(es) above, also submit one copy of this form within 30 days o
13b.Disinfection type: Amount: completion of well construction to the county health department of the count
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-201