GW1-2021-00364_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:n`
UxN I ANk ly 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
XyJC I�VL 1ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cused'wells OR LINER if a licable
FROM TO DIAMETER THSCKNE`S,S MATERIAL
ft. in. S� —1 o P v/
Company Name V
I��� 16.INNER CASING OR TUBING, ''eotherntal closed-loo "
2.Well Construction Permit#: &d FROM TO 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. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public "aO,tt, 33ft in. } a VG
:,')Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
_'Industrial/Commercial _.i IResidential Water Supply(shared) 18.GROUT.;
lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
__'Monitoring DRecovery ft. oC ft.
Injection Well:
Aquifer Recharge D Groundwater Remediation
_ Aquifer Storage and Recovery 19.SANWGRAVEL PACK If a licable[]ISalinityBarrier
FROM TO I MATERIAL EMPLACEMENT METHOD
:)Aquifer Test OStormwater Drainage ao ft- `�3 ft. #_�^
5C May
_ 1
I ft Experimental Technology 0ISubsidence Control . ✓ ft. oC
B
Geothermal(Closed Loop) MITracer 20.DRILLING LOG(attuch additional sheet£'if necessaGeothermal(Heating/Cooling Return) �IOther(explain under#21 RemRemarks)ks) FROM TO DESCRIPTION(color,hardness,soil/rock ty e, rain size,eta)
ft. � ft.
4.Date Well(s)Completed: b Well ID# ft, ft. O
5aeWell L/o{caattion• ft. &L) ft. C)r �Vl I< 1 �M&m Oft. ft.v! Q ft. 3 2 ft.
F ility/Owner Name�n Facility ID#(if applicable) ✓J
1�1 t� C ft. ft.
Physical Addres ity,and Zip /�
013
q I`3 �Q 21.REMARKS
en 1 O '
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) 22.Certification:
3,50 19•�r)'j N _U° 3 I. '71 o w a Lao
6.Is(are)the well(s)II](11Yermanent or 1ITemporary Signature of Cer ed Well Con for Dat
777T''' By signing this form,1 hereby certifv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EIYes or 16i No 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: 2 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �/� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(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 Iniection Wells: In addition to sending the form to the address in 24a
� above, also submit one copy of this form within 30 days of completion of well
�`` A
12.Well construction method: {u 2A�aYvv—
(i.e.auger,rota p ) construction to the following:
( g rotary,cable,direct push,etc.
Division of Water Resources,iUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Ol Method of test: um i 24c.For Water Supply&Iniect ion Wells: In addition to sending the form to
U a the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1 ,� Amount: t 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
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