GW1-2022-03477_Well Construction - GW1_20220323

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.WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor
Information:
JV 1,11 VT!u'1 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
L z - I 31D ft, s kP
NC Well Contractor CCertification Numlbw n0 ( EOM Is.OIII'mcAsEgG'(inrmum;eased we OR'LII9EA Ita ttcabte
C( 1 ( v l� _[_�J r„ TO DIAMETER THICf{NSSS MATERIAL
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ft-
t 3 fb in-
Company Name
16.INNERCASING ORTUBING eothermal dosed-loon)
2.Weil Constracdon Permit#: FROM TO DIAMETER TMCKNESS I MATERIAL
List all applicable well construction permits(i e.UIC,Cout*,State,Variance,etc.) ft. m'
3.Well Use(check well use): ft' ft. 1°
Water Supply Well: 17 SCREEN
FROM TO I DIAMETER I SLOT SI12; THICKNE53 MATERIAL
Agricultural � chpaltPublic 0 ft, ft, in.
Geothermal(Heating/Cooling Supply) Okesidential Water Supply(single) ft, ft, fIl
Industrial/Commercial []Residential Water Supply(shared) Is.GROUT
Irdization FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft IL Al
_Monitoring Recovery fL ft.
Injection Well. 'r
quifer Recharge DGroundwater Remediatian JrL fL
19.•SAND/GRAVBLPACH d licable
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) ElTracer 20..DRILLING LOG(attach additional sheets if n
Geothermal Heatin Cooli Return) Other lain under 921 emarks FROM To DffiCRH'rION tutor ruudnlss�tUmek ete
ft. ft.
4.Date Well(s)Completed: 3 -1'&2�lWe11 II)i A 7 ft• ft. ". _.�'
5a.Well Location:
t ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft' ftLt
7— 7-5- e e // 410#r'A
rr
e:r,
Physical
Address,City,and Zip It. IL
'
Ae3o n 21.REMARKS
County Parcel Identification No.MN)
56.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.nCe7ltj
Ita 02-Zq 7. 761261 79 W-5-4.�rsZ�q "W
.3-9-2oz2
rmanent or Temporary Sign of Certified We atractor Date
6.Is(are)the well(s)eft,signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or 0To with 13A NCAC 02C.0100 or 13A NCAC 02C Moo rltell Construction Standards and that a
1f 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#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: cr BMrrTAL nv9rRj1LCjL0M
9.Total well depth below land surface: 60 (ftJ 249.For All Wens: Submit this form within 30 days of completion of well
For multiple wells list all depths If different(example-3@200'and 2®100 j construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources.Information Processing Unit,
lFwater level is above casing.use-+- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. ` (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
tK 1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction metiwd: /t! constriction to the following.
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources:Undergnovnd Inje tan Control
FOR WATER SUPPLY WELLS ONLY: n 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 10'.) X r. `244,For Water Sup]&&Injec[on 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: v l.t.,cc '�._ completion of well construction to the county health department of the county
where constructed.
Fonn GW-1 North Carolina Department of Envimmnental Quality-Division of Water Resources Revised 2-22-2016