GW1-2022-08316_Well Construction - GW1_20220518

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Well Cont�1�l
.. 14::WATER'ZONES.._._
.•-. ?;;'-.,:i;:. •. -- .....
for Name
FR M TO DESCRIPTIO
L 1 ft. ft. �� vril
ft. ft.
NC Well Contractor Certification Number
15rOUTER:CASING(for iniilti RLINER(ifwOplicable
FROM I TO DIAMET THICKNESS MATERIAL
Company Name of A;��\ 1p 16.1NNER'CASING OR TUBING; �ebtlicrm �al closed-Ito .`.
2.Well Construction Permit#: r 1/ L L�+� v V FROM To I 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.
17.:SCREEN.;,. ...
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipaUPublic ft. 1 ft. in. p)
a o ��
—,I Geothermal(Heating/Cooling Supply) Water Supply(single) ft ft in.
_: Industrial/Commercial ffResidential
Residential Water Supply(shared)
18:-;GROUT'; i
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © ft. a C) ft. 'Bet °-n t q bqlss
1-Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
_ Aquifer Recharge Oii Groundwater Remediation
.19.SAND/GRAVEL PACK(if iO licfiblc
Aquifer Storage and Recovery
ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stonmwater Drainage O ft. LP
Experimental Technology FnISubsidence Control
Geothermal(Closed Loop) FMITracer 7 20:`DRILLING L'OG,(5ttuch addithihal sheets if necessar`)
FROM TO DESCRIPTION(color,hardness,soiUrock ty e, rain size,etc.)
BGeothermal(Heating/Cooling Return) I Other(explain under#21 Remarks) ft.aft ft. �" b�
4.Date Well(s)Completed: Well ID# ft. 1- ft. t' ' Se n a
5a.Well Lo ation: ft. t ft. Q ry _ �j�; q
\C. ft. ft. sar G MV--C
Facility/Owner Name Facility ID#(if applicable) ft. ft. n i a
IV ft. ft.
- hd
Physical
�Address,City,
and Zip ft. ft.
a �1.11 x 21.REMARKS
County Parcel Identification No.(PIN) 1 - t 1 �~ ►'•ry0=`"'s"- L ��t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35° r�'3.LA% N �� . �-I� w t 6-1-ate
,, .���
6.Is(are)the well(s)il/`9Permanent or )Temporary Signature of rtified Well C ntractor Date
77�� By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: (nYes or No with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided io the well owner.
repair under 1121 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
�M above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: i t I� 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(`(1�j(� 24c.For Water Supply&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: Amount: 1/Z completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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