GW1-2021-00710_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
VA r Information-
, r 14.WATER ZONES
Well Contractor
nNa a FROM TO DESCRIPTION
ft. a ft. +0.1l Sand
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased weits)OR LINER if a licable
11� � FROM TO DIAMETER THICKNESS MATERIAL
1 \ t` ft. a t ft.
in. �� PK,
Company Name
��� 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: (���� —� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC County,State, Variance,etc) f[. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
Agricultural OMunicipal/Public l ft. a ft. in. I � ��
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) 1 tt. ft. in. �Y
-, Industrial/Commercial Residential Water Supply(shared)
18.GROUT'
IrrigationFROM TO MATERIAL EMPLACEMENT METHOP&AMOUNT
Non-Water Supply Well: ft. it. t1i l
Monitoring O
Recovery
Injection Well:
_:Aquifer Recharge Groundwater Remediation 19.SAND/GRAVCLPACK it a 1
t. t.
icable
Aquifer Storage and Recovery EISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
__,Aquifer Test IStonnwater Drainage -go ft. ft.:)Experimental Technology r.JI Subsidence Control
_,Geothermal(Closed Loop) nlTracer 20:DRILLING LOG(attach additional sheets if necessary)'
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock a rain size,etc.)
--
ft. ft.
4.Date Well(s)Completed: �� �� � Well ID# O b
5a.Well Location:
it. ft. �!
ft. ft
Facility/Owner Name``ll � Facility ID#(if applicable) ft. t� ft. \�
Ob W Val G ft. fL
Physical Address,City,and Zip ft. ft. DEC 0 8
( a 2 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'
Igrl�, 1 N W
6.Is(are)the well(s) Permanent or CITemporary Signature ofCerti d Well Contracfor Date
0 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 ONo 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 informaliom0d explain the nature of the copy of this record has been provided to the well owner.
repair under#21 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: I (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3 00'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
12.Well construction method: ' l IyU 1\�)��"i 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
1, I
13a.Yield(gpm) �" Method of test: Um 1� 24c.For Water Supply&Iniection Wells: In addition to sending the form to
L 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 Resource's Revised 2-22-2016