GW1-2021-00359_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Informatiton:
I�yV� t'N I1 14.WATER ZONES
Well Contractor Na FROM TO DESCRIPTION
ft. S ft. 1
117t,L ft. ✓ ft. 1
NC Well Contractor Certification Number 15.OUTER CASING for multi-edged wells OR LINER(if a licable
1\, FROM TO DIAMETER THICKNESS MATERIAL
L {-, ft. Iq ft. in. .(.O
Company Name 1 `AC
16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: W a D I I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,Mate, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �Munici I/Public I ft. ft. a tn. �� b C�I�D wL
__I Geothermal(Heating/Cooling Supply) _ sidential Water Supply(single) ft. ft. in•
:3 Industrial/Commercial 17'IResidential Water Supply(shared) 18.GROUT
liTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © ft. ft. (Jen-V.4 r, 5-
Monitoring DRecoveiy ft. ft.
Injection Well:
ft. ft.
_ Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if,apolicable
Aquifer Storage and Recovery FnI Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStonnwater Drainage Oft.
Experimental Technology r.1ISubsidence Control ft. ft.
Geothermal(Closed Loop) FnITracer 20.DRILLING'LOG(attach additional sheets if necessary)'
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
BGeothermal(Heating/Cooling Return) IOther(explain under#21 Remarks)
0 ft. a fL
4.Date Well(s)Completed: � Well ID# ft. ft.
5a.Well Location:
--vat-
Facility/Owner W�l 7C GZ
Name�(�p�� Facility 1D4(ifapplicable) �8 ft. 1 ft. QL Nam
1a q l riO V liY 1l Y��0�� win Waof y t ft. ft. Y
Physical Address,City,and Zip ` -7 ft. ft.
t � � it)
b 11 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3S� 11IQLP N lD 30.a W � � e nr"Ali';�Idl'� �='� _�iiia1Ji4F
6.Is(are)the well(s) ermanent or IOTemporary Signature of Cb4fied Well Co ctor 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: (DYes or [Z F with ISA 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 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 well
construction,only I GW-I 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: A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierem(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
,/fin, C p a La above, also submit one copy of this form within 30 days of completion of well
i..Well construction method: t 1 ll/ttJ� �C�TG� 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) I Method of test: rfl l 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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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