GW1-2022-07897_Well Construction - GW1_20220829

nt Form
WELL CONSTRUCTION RECORD(GW-1) F r Internal Use Only: PH
1.Well Contractor Information: ( <
"DESCR
ES
Well Contractor Name DESCRIPTION
(���+ �/�/� � (z ft.l V-l �11 C— YC 7Q3ft.NC Well Contractor Certification Number
G for multi-cased wells OR LINER if a licable
uadtas ` lQQ � DIAMETER THICKNESS MATERIAL
ca, t ft. in. -7VCompany Name o2t� r//�� G OR TUBING( eothermal closed-loop)
2.Well Construction Permit#: IJ� ! FROM TO DIAMETER THICKNESS 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
FR M TO DIAMETER SLOT SIZE I 'THICKNESS MA•rER1A1,
Agricultural ®Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial I DResidential Water Supply(shared)
18.GROUT
Irrr ation FR M TO MATERIALInd EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. l ft. C-Trae
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery
^Salinit Bander 19. AND/GRAVEL PACK(if a licable)
1J' Y FR M TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormrwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20. RILLING LOG attach additional sheets if necessa
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FR M To DESCRIPTION(color,hardness,soil/rock type,gain size,etc.)
t ft. I ft.
4.Date Well(s)Completed: ova Well ID# I't.
ecom
5a.Well Location; {` ft. 0 ft, c
�It
Facility/Owner Name Facility ID#(if
\applicable)
1'(1P.�UC� ft. ft.
Physical A ,City,and Zip
40166 ro f:G !I t 21. EMARKS
County Parcel Identification No.(PIN)l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.C rtiflcation: , n� c� /
N W t 0uf�'
6.Is(are)the well(s) Permanent or Temporary 03'
at re ofCcrtified Well Contractor Date
dg ing this/orm,I hereby certi&that the well(s)was(were)consu•ucted in accordance
7.Is this a repair to an existing well: [Dyes or No 1 A NC.AC 02C.0100 or 15A NC4C 02C.0200 Well Construction Standards and that a
If this is a repair fill out known weld construction infornnattor an explain the nature of the o(this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You i any 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 constiuction details. You may also attach additional pages if necessary.
drilled: _ f SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Ey)W --(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdlffereitt(example-3@200'and 267100) construction to the following:
10.Static water level below top of casing: %M ( ) Division of Water Resources,Information Processing Unit,
IJ'water level is above casing,use"+^ ft.( 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: le (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method j i I above also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.)
constriction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
11 13a.Yield(gpm) Method of test: 24c.For Water Sunply&Injection 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: qk? l` Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Qual tv-Division of Water Resources Revised 2-22-2016