GW1--01760_Well Construction - GW1_20240320

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1
1. .ell Contractor Informa'on: .
G dr 1),P 14:WATER ZONES
DESCRIPTION
Well I.tractor Name FROM TO
,gio -. 4 /6.,ft /*v ft ft. V, 5 6r�
iNC Well Contractor Certification Number
• / / ,15.OIJTERCASING(for mi Iti.cdsed-we1LOOR LINER(rip'1PL1C
Rcabte) •„'-
�/i Ji J /e FROM TO DIAMET THICKNESS MATERIAL
C..li r C+�' / ft. /J ] ft. 6 t in. 5 0_1 -
Comps Name (/Ji
1 (1 01 C 6 '16 IN1NER CASING'OR TUBiNG(geothermal'closed=loop)
2.Well Construction Permit#: THICKNESS MATERIAL '
FROM TO DIAMETER THICKNESS
List all applicable well construction permits(le.UIC County,State,Variance,eta) ft. ft. I in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:`SCREEN'" t
FROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft in.
Industrial/Commercial °Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft it
Monitoring ORecovery
Injection Well: -
A Aquifer Rechargeft.
9 OCmoundwater Remediation
Aquifer Storage and Recovery .19:SAND/GRAVEL"PACK Of applieable) ' _ -;-:,--1-:Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test jStormwater Drainage aft. o 5 ft. Ix� � /1,e� j u✓
Experimental Technology °Subsidence Control ft. ft �
Geothermal(Closed Loop) [Tracer 20.DRILLINGLOG'(ittajh addrhonal sheets,ifneceisarg);:=
Geothermal(Heating/Cooling Return) i1Other(explain under#21 Remarks) FROM TO DESCRIPTION(actor,hardness,sun/rock type gain sUc etc.)
a ft ,i' G' it /7Ye, e-/ecy
4.Date Well(s)Completed:3 75 .V Well ID# /aD ft. //2 ft G',y'jc r jC-
5a.Well Location: 7/c ft ) 'S ft C i t.L''
/1,4 v/# Lv?91/40 //- 2 f 7-ifif ft
'ic 6 ft' MAR 2 02024
Facility/Owner Name Facility ID#(if applicable) ft. ft
5'07 9 C"'tYl /;/€/ e//%/if t(" l/U' ft. ft Ifti+ii��egtz;1 P.rr.n '*:'Fl Eis-'•
Physical Address,City,and Zip ft ft: !isf 4C117:Jw
{
• r,fTrry") �U(/ .Y.j 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: /
(if well field,one lat/lan is
iss sufficient) ) 7 22.Certification:el2(._ og—�
5S6)a � �5G N 1`v0' ° �5-. 1 W
6.Is(are)the well(s) Permanent or Temporary Sig¢a °i Ce Well Contractor J Date
• By signing this form,thereby cent{that the_We ll(s)was(were)constructed in accordance
7.Is this a repair to au existing well: Dyes or o ~ with 15A NCAC 02C.0100 or ISA 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 ofthis 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:
,,{ 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 PfdBerent(example-3Q200'and 2(§100)
construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1 17 nit,
11.Borehole diameter: l i l (in.)
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: •4/ / < G c V above,also submit one copy of this form within 30 days of completion of well
(ie.auger,rotary,cable,direct push,etc.) / construction to the following:
Division of Water Resources,
FOR WATER SUPPLY WELLS ONLY: Underground Injection Control Program,
�/ 1636 Mail Service
Center,Raleigh,NC 27699-1636
13a.Yield(gpm) f r 5 Method of test)t n 'tat.r Qrt 24c.For Water Supply&Iniecti i n 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 Gy completion of well construction toq the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
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