GW1-2021-00720_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: /,
LFW 1M V `�(�\11 ' v, '� —SyV14.WATER ZONES
Well Con cttoor1N(a� a FROM TO DESCRIPTION
v�Y3 e.`
ft. J�� fL cAl^ti
NC Well Contr ctor Certification Number i 1 15.OUTER CASING for multi cased wells OR LINER if a licable
FROM TO DIAMETER TffiCKNESS MATERIAL
VVVV \ YYY 1 ft. �� ft. in. �. 1�1 U�
Company Name
16.INNER CASING OR TUBING eotherntal closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) A ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. o�C7 ft. intb,nt
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
_ Aquifer Storage and Recovery F7ISalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage C�n 3o ft #a SCL� pv��l
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) []]Tracer 20.DRILLING LOG(attach additional sheets if necessary)
_ G FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)eothermal(Heating/Cooling Return) ]Other(explain under#21 Remarks) ft. �� .
Q ft c)
4.Date Well(s)Completed: L� "�^oZeil ID# ft. ft.
Sa.Well Location ft. ft.
\
`5 Y�ts � ft. '30 ft- A—c rN r s,. d � �QY
Facility/Owner ame 1, Facility ID#(if applicable) f. J ft.
Physical Address,City,and Zip ft. ft. 202 1
�C ", 115AI 5'l KS^� '�jl�(,tt 21.REMAR
County `n 1 Parcel Identification NNo..I(P(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) � 22.Certification:
3 l _ -3 LA�S Q N � D 1�t,o�Jyy la W e , i t-a y ray
6.Is(are)the well(s) Permanent or OTemporary Signature of C ified Well Con btor T 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: E)Yes or 1No with 15A NCAC 02C.0100 or 15.4 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 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: EX0 (N 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3 @2,0,0'and 2@I00� construction to the following:
f
10.Static water level below top of casing: � (ft.) Division of Water Resources,Information Processing Unit,
If i.ater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: to (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
nn above, also submit one copy of this form within 30 days of completion of well
12.Well construction method t�i � Yl/>i construction to the following:
(i.e.auger,rotary,cable,direct push,ettc.)c.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 01 Method of test: 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