GW1-2022-01671_Well Construction - GW1_20220128

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
I
M i y�rl G t bjr ..I4,WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
7D
6��_ ft- )low
ft 2
NC Well Contractor Certification N,unbbeer( 15 OUTER?CASIN O fdri ifttf�¢ai<ed;wells R'I1NER((It_ IkaDle
W P 5 "CX 1 I hC FROM TO DIAMETER TtIICKNFSS (MATERIAL
ft ft. in.
Company Name (, I 16i1NNEWCASING>ORTUBING "eotheimiil'do"sed=loo Yz zry
2.Well Construction Permit ii: I 1 v 1 _ FROM I To T DIAMEM IWOU4 ss I MATERIAL
List all applicable well construction permits(ie.UIC.County.State.Variance.etc.) 6ft T. R. .2 io.
3.Well Use(check well use): ft. ft. in.
17:SCItEEN
Water Supply Well: FROM TO DIAMEIBR SLOT SM THICKNESS MATERIAL
Agricultural [3M cipaI/Public ft. ft. in
I
Geothermal(Heating/Cooling Supply) EKUidential Water Supply(single) ft. ft. in-
Industrial/Commercial 1311esidential Water Supply(shared) 18:'GROUT '
IrriRation FROM in MATERIAL EMPLACIRAIIIYr METHOD&AMOUNT
Non-Water Supply Well: C) ft' 6 ft' UVdZ
Monitoring DRecovery ft. ft. cW
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
*I9SAND%GRAVBIf�AGg.
Aquifer Storage and Recovery Salinity Barrier FROM I TO I MATERIAL I E UILACFaMEN r METHOD
Aquifer Test [3 Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. M
Geothermal(Closed Loop) Tracer 26 DRILLING LOG t(ntlaeh'aaaliio"nalsheefsaf_
a�iUrork o
Geothermal(Heating/Coolie Return Other(explain under 1121 Remarks) FROM TO DESCRH'TION color,bsrdn sire etc.)
G ft- 7/ ft. C Iat v�j-b Ura(p�
4.Date Welt(s)Completed: 7—.Z a Well ID# 7(v ft. ds fr. vl�h t
5a.Well Locatiron^ R. ft.
: t
Facility/Owner Name Facility ID#(if applicable) ft. ft.
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a14 Ae-ftkee QAj Dr. r/1!fP�ale/UC 1$73 2 Q2�
Physical Address,City,and Zip
21 ft ft'
4-X'�ltt�t'�� IVStid !yylOt� REMARRSi
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Cifwell field,one lar/iong is sufficient) 22.Certification:
-3S° 24 ' -25-74A N 820 IN t 46- W
6.Is(are)the well(s) ent or Temporary 11
goature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
0 with 15A NCAC 02C.0100 or 15A NCAC 02C A200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or
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 P21 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-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: �d 5 (R•) 24a. For All Well : Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 1Q10a) construction to the following:
10.Static water level below top of casing: -7 (fit.) Division of Water Resources,Information Processing Unit,
If water level is above casing,tote"+" 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter. �O• Z (in) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of ibis form within 30 days of completion of well
12.Well construction method: 0 TGIY� 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) Method of test L 4 0 0— 24c.For Water SuoDly&Injection Wells: In addition to sending the form to
the address(es) above, also subinit one copy of this form within 30 days of
13b.Disinfection type:.Cln I W Amount: 5 4rxbS• completion of well construction Ito the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016