GW1-2021-02568_Well Construction - GW1_20210930

WELT.,CONSTRUCTION RECORD(GW!!I) For Intealal Use Only:
1.yutr ctor I:E�/
34-WATMZONES` _
FRObi TO DFSCRIP'r1ON
Well Contractor Name
•�y ft. ft.
NCWeiICo tractor Certification Number -15.OUT'ER UASINGVormtllti�ase -ells ORLINER ;a Ucable
FROM I TO
Company Name 26'1NNSR EASING OR TIIBING etiihermsl dosed44a .,
Z Well Construction Permit#:&fd�(�Q 6 0 F&011i TO DIAMETER TffiG7QVESS ;tvinreninL
Ust allapplicable well consimcnan p rits(t.e UIC County,State,Variance,etc.) R f,L to
3.Well Use(check well use): ft. ft
Water Supply Well: MFROATREEN A M K
FRt1hS TO DIAh2ETER SLOT SIT.£�. THICKNESS I�MATERIAL`..
❑Agricultural ElMunicipal/Pablic t Z in.
©Geothermal(Heating/Cooling Supply) AGtesidential Water Supply(single) fL IL in.
❑Industrial(Commercial OResideatial Water Supply(shared) -111.GROUT
L7lrri ation ❑Wells>100,000 GPD rRoat To MATMLtr FT+r17 A c METHOD& OUNf
Non-Wafer Supply Well: fL 4zs✓
❑Monitoring gRecovery ft. fL
Injection Well:
ft. ft.
❑Aquifer Recharge OGmundwater Remediatian
19 StkIVDlGRAVELYACK d applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EhtPLACENfENrAMMOD
❑Aquifer Test ❑StormwaterDrainage Rtj,SR t, jy
OExperimental Technology OSubsidenee Control it. ft
❑Cieotbetmai(Closed Loop) ❑Tracer DRUsLIIVGL(}G attach addrtioiinl%heetsiEnecess ' r
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,bwftes4 sottirocx etc.
C} % fL
4.Date Well(s)Completed: / 4 2 Well ID# ft ft
Sa.Well Location: fL it
l X ft. ft.
Facilily/OwncyRatim Facility M#(if applicable)
Physical Address,City,and Zip % it
{ 2L REMARI{SSER
<< a
Cmmty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: SqC-i-inn
(if well field,one lat/long is sufficient) 22.Certlfi n:
J 77' ZZ N —1 0 `' W
6.Is(are)the weU(s):Aermanent or ❑Temporary i t a Contractor Date
signing thisform,I hereby certrfy that the tvell(s)ims(here)construded in accordance with
7.Is this a repair to an existing well: ❑Yes or AN. h• 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has-been provided to the well owner:
repair under#21 remark section or on the Lack of thirjorm.
23.Site diagram or additional well details-
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: e� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �6 7 __ _(ft) Submit this GW I within 30 days of well completion per the following:
For multiple wells list all depths ifdijjesrait(exanipte-3 00'and 2@100)
2 t f� 24a. For All Welts: Original form to Iiivision of Water Resources (DWR),
10.Static water level below top of casing: 1 ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwarer level is above casing.use"+^
/ 24b.For Injection Wells:Copy to DWR,`Underground Injection Control(IUC)
li_Borehole diameter: CM.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: "IP.4 kAa f 4 24c.For Water Supply and Open-Loop Geothermal Return Wens:Copy to the
(i.e.auger,rotary,cable,direct push et.) � 4 county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: f� y� 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(ggm) SO Method of test-. /sy1�71 Permit Program,1611 MSC,Raleigh,NC 27699-1611
)3b.r?isi?;t:;rl?izt?type` _.__... Amount.
777777"' I
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