GW1-2022-07067_Well Construction - GW1_20220722

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WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well=tInati rrr 14.WATER ZONES
WellactorNamc FROM TO DESCRIPTION ,.
NC Well Con r Cc f atio>Numhcr 15.OUTER CASING for multi-cased mells R OR LINER if applicable)
r/
(..�L -� ��nS
FROM TO DI.1.11ETER TBICIi.VFSS �IATER[AL
f/ �ft. ft. in. s'L Sfo L,L_
Company Name I;,
16.1NNER CASING OR TUBING eotheFinal closed-too
2.Well Construction Permit#: J ?� j'� FROM TO DL1.METER THICIiVESS 51ATERIAL
L s?all applicable well consintetion permits(i.e.UIC.County.Siatc.I-ariance,etc.) ft. ft. in.
3.Well Use(check well use): fr' ft. in.
Water SupplyWell: 17.SCREEN
/ FROM TO DLIDIETER SLOT SIZE TBICKNESS 31ATERIAL
Agricultural (11_cipal/Public 7t. J�Jt. in. , J SC GJv
��
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fr, ft. in.
Industrial/Comtnercial E31tesidential Water Supply(shared) 18.GROUT
hTigation FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: - 0 ft. � ft. ,, - 'C�/f -
Monitoring ft. ft.
Injection Well: ft. ft.
Aquifer Recharge roundtvater Remediation
19.SAND/GRAVELPACK.(if applicable)
-
,Aquifer Storage and Recov EISahnity Barrier FROM TO MATERL%L EMPLACEMENT METHOD
Aquifer Test Q Stormwater Drainage tt.
L•xperimentai TechnoI Subsidence Control (�
Geothermal(Cl. Loop) Traci r 26.DRILLING LOG(attach additional sheets if necessi )
Geothermal( eating/Cooling Retum) 00ther(explain under=21 Remarks) FROM To DESCRIPTION(color, ardness,soil/rock type,grain size•etc.
t J ft. ft. �Jj, 3C7i j
i
4.Date Well(s)Completed:• t)l �, Well ID# fr. .�0 ft. C/
5a.Well Location:
nuoa
Facili[}/OanerNanre Facility iDn(if
pllicab/llee)
r Physical fr. ft.Address,Clty end Ziff
:7p ( 21.RENIARKS
Count), r! P-reel identiticatior No.(PiN) W*C0n*+Qn ProCasming Unit
VVPW30G
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifn•ell field.one]oat Iona is sufficient) 22.Cerq cation
' si6 art rr-r!t Certified Well Contractor ) Date
6.Is(are)the wells) ermanent or Temporary =
-Br signing this.toriu.I hereby certify that the well(s)lvac(were)constructed in accordance
7.is this a repair to an existing well: [Dyes or ImoN ,i1th 15A XCAC 02C.0100 or 15A\'CAC 02C.0.00 Well Construction Standards and that a
yehis is a repair,Jill out k norm trell construction information and explain the nature ojthe copy ofthis record has beer prat ided to the well owner.
repair under=21 rennarlrs section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells havin'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: SOBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
Fur•multiple wells list all depths ifdiercm(example-3 a 2uli'annd 2@100') construction to the following:
10.Static water level below top of casing: C (ft.) 'Division of Water Resources,Information Processing Unit.
lfuater level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: y (in. 7 24b.For iniection Wells: In addition to sending the form to the address in 24a
/1 above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct pr>_`•h.etc.) `
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
//n
13a.Yield(gpm) Method of test: - 11 24c.For Water Suoaly&Iniectiori Wells: In addition to sending the fornt to
the address(es) above, also submit one copy of this form Mthin 30 days of
13b.Disinfection type: G4 ,-LEA Amount: completion of well construction to the county health department of the county
where constructed.