GW1--02739_Well Construction - GW1_20240506

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor motion:• 4 /�y/GGli eft
14.WATER ZONES -. I,
FROM TO DESCRIPTION
Well C ctor Name
- M' eft aa-a ft S c�,�
NC ell Contractor CertificationNumber
3 3 1, 7 �/
n 15:OUTERCASING(fur:malts-cased wells).ORLINER(If al iicable)
, �1/n�-��la t�r�/� L�l//, AL
�M TO.� DIAMETER
THICKNESS
a� ����C
2.Well Construction Permit#: /� G ' 'ft' Of y.) do(
TO GORTUI3tN DIAMETER ermaiTHICKNESS MATERIAL
List all applicable azd construction permits(i.e.UIC County,State,Variance,eta) ft ft. in.
3.Well Use(check well use): n• ft. is
Water Supply Well: =17.SCREEN i s
FROM TO -DIAMETER SLOT SiZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidenttal Water Supply(single) ft. ft. is
Industrial/Commercial . E3Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. it.
Monitoring QRecovery It. , ft. •
Injection Well: .
ft. ft.
Aquifer Recharge EiGroundwater Remediation
• 19sSAND/GRAVEL PACK(ifapplicable)
• Aquifer Storage and Recovery Qsatinity Barrier FROM TO I)MATERIAL EMPLACEMENT METHOD
Aquifer Test [jStotmwater Drainage IL dc% ft /�L/ililtt. A/rked Giv
— Experimental Technology EDSubsidence Control It. ft
Geothermal(Closed Loop) 10Tracer 20.DRILLING LOG(attach additional sheets ifnecessary) . . '
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(rotor,hardness,soiVreek type.grain size.eta) •
6, ft. � ft. /� `P of Clc
4.Date Well(s)Completed:3.u ` / Well ID# 70 ft. ft. ,-'o iris-e-
5a.Well Location:. ie:?ft. .�y5 ft. . 4.q.,-e/tom
0-6AA07 C-&/r y lt�a7 i e. 10 /0 /7 ft. P
Facility/OwnerNamc Facility iD#(if applicable) R' ft. t .E'.-.d .,Z . 1 :. .
3 I c 16KMri•e t'[.e 2.� .f ft. . MAY 0 v [6[4
Physical Address,City,and Zip
L.fir caw ,'aila' J 21.REMARKS . lrf;, -- -
County Parcel Identification No.(PIN) L v C. . Ch aµ
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �{^ t�
(if well field,one lat/tong is su cient) J _ 22.Certification:acif&a-Pt
1„i Ch iVueQL a 2r
6.Is(are)the well(s)0 Permanent or Temporary Siena of Certified well Contractor I Date
By signing this form,1 hereby certify that the well(s)was(were)constructed hi accordance
7.Is this a repair to an.existing well: DYes or I( i o with 1SA NCAC 02C_0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fdlout known well constrnctlon information and explain the nature of the copy of this record has been provided to the well owner.
repair under#1I remarks section or on the back ofthisform.
. 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--I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS '
i
9.Total well depth below land surface: L/ (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths f different(example-3Q200'and 22 100') construction to the following I
10.Static water level below top of casing: ! C/ (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
++__l
•11.Borehole diameter: 1p` +3' (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ,rC 1' is,/y construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Resources,FOR WATER SUPPLY WELLS ONLY: 1636 Mail ervice Center,Raleigh,N Injection Program,7699-1636
13a.Yield(gpm) a a Method of testR` \+' ? 24c.For Water Supply&Iniectionl Wells: In addition to sending the form to
� the address(es) above, also submit one copy of this fonn within 30 days of
13b.Disinfection type:
% i Amount: 3 c(./ r J completion of well construction to Ile county health department of the county
where constructed.
r•-,,rur_r North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016