GW1--03284_Well Construction - GW1_20240528

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WELL CONSTRUCTION RECO (GW-1) For Internal Use Only:
1.Well Contract° Inforation: a IJ I„ I m
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/I 3/ri Q�•-`r 1/.WATER ZONES -
WellContrauorName FROM TO DESC1t1P sett
3S35 . 4O0ft. 1-1,0 ft ft ft. -
NC Well Contractor Certification Number
15.OUTER CASING((or niuhi-cased wells)OR•LINER(if ap tJGable)
13 el)1--'�--, -e_l�S FROM TO f_pl4Mrrla THICKNESSmpany
Co Name ft I ft I - I
2.Well Construction Permit#: 16.INNER CASING OR TUBING(geothermal dosed-loop)
FROM TO DIAat TIER THICKNESS MATERIAL,
List all applicable well construction permits(l.e.UIC County,State,V etc.) -t•-' ft I ,I e k ^t j 1
3.Well Use(check well we): ft. e4. ��E�aer J
Water Supply Well: .17E SCREEN _- ✓
OAgriculdualFROM TO 'oi:�lilirt'1i ' SLUT'SIZE THICKNESS MATERIAL
Alifunicipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft R. in.
❑Industrial/Commercial Residential Water Supply(shared) ---
❑irrigation 13.GROUT
❑Wells>100,000 GPD FROM TO MATICAIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: - t. ft• -
❑Monitoring • ❑Recovery R
•
• Injection Well: ft.
• • ❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
19.SAND/GRAVEL PACK LI■pplicable)
❑Aquifer Storage and Recove
ry ❑Salinity Barrier FROM TO MATERIAL EMPIACIDfENT METHOD
❑Aquifer Test OStormwater Drainage ft. ft `
❑Experimental Technology ❑Subsidence Control ft ft
•
• ❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets ifue a.try)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remit FROM TO DHSCRI1rITQN(color,i�vases n„7/raclr tau p,;a rig etc)
ft. ft
4.Date Well(s)Completed:5 ZZ.4_1 Well -IAn' ? ft. '11. �L 1 `
5a.Well Location: 1 ft ft
C, z s ; fy -
/A0(gal-, ._Shafly ft. R
• Faca7ity/Owrcr Name facility IDM(if applicable) ft ft, _14 r , _e (�,. -
ki-2{ _C a LA d e.. !v 1 c�5+- R J . .,Eft ft "11 1f N/ r t S j�
Phys' Address,City,and Zip R R !`�
/Z h 1- • 21.REMARKS/
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County Parcel Identifration No.(PIN) •
(f Latitude and longitude indegrees/minutes/seconds or decimal degrees: a�a
(if well field,one lad is sufficient) 44J4
`
22 Ccrtifi lion:
la ,.1 55' N 3/ 1 2.3 / 35 W r-
6.Is(are)the well(s): WPermanent or OTemporary Signature of CeztiSed iVell Comractac Date
B
signing this form,1
7.Is this a repair to as existing well: ❑Yes or No ISANG4C 02C:0100hor 15AN•;eby AC.02C.0200 that the Well Construc was tion Standardsconstruer and that a ced in accordance opy If this is a repair,fill out brown well coma uction information explain the nature of the of dim record leas been provided to the well owner.
repair under 121 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info •
8.For Gcoprobe/DPT or Closed-Loop Geothermal Wells having the sume
(add'See Over'in Rercarim Box).You may also attach additional pages if necessary. •
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: L Q (ft.)
For multiple welly list all depths if dtfjerenr(example-3®200'and s'(t�100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: yQ (ft) 24a. For All Wells: Oribtiaal form to Division of Water Resources (DWR),
If wader level is above caring',use'+~ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 61
din) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
i7 ±a r Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: -R d e� _
(i.e.auger,rotary,cable,direct punt etc.) ` ) r24c.For Water Supply and Op cu-Loop Geothermal Return Wells:Copy to the
county environmental health icpartment of the county where installed
FOR WATER SUPPLY\YELLS ONLY:
^ 24d.For Water Wells pr°d acing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test A-j r Permit Program,1611 MSC,Raleigh,NC 27G99-1611
r,
13b.Disinfection type: I 7 I4 Amount: f 2-, /rj---
Form OW-1 North Carolina Depart neat of Ervir:aunt: et Quality-Division of Water Resaaces _ -