GW1--03835_Well Construction - GW1_20240628

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
C7 (. 1 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
a 1 ft. 3 0 ft. d
LIS 7 7 A G � 3,-ow.\
'P► 1., +�NC'Well Contractor Certification Number i30 ft ( 15' / 6-9M
15.OUTER CASING(for multi-cased well yOR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MAATERIAL,
Company Name d ft. 1 J ft-
t I//I in. ` 2 o"1 , ✓t t! -
16.INNER CASING OR TUBING(geothermal closed-loop)l ( Le
nlce
2.Well Construction Permit#: FROM TO DIAMETER, _ THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.) (' fit. too
ft (.1to SCh Yo P V�
3.Well Use(check well use): ft. D ft. in. 1
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. M.
Geothermal(Heating/Cooling Supply) D Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: n// '',,--11. y�
PP 0 fL t�41p rt. � i'EDIl.pI_J POLitL•c� � a � in P�
Monitoring Recovery ft. �j ft. ,l,. 1 h 3
Injection Well: O OU �� �J°/rE�Ix" ��G DS
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMEN I METHOD
Aquifer Test IJStormwater Drainage ft. fit.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) DTraccr 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) fit fit Re j
(O 4.Date Well(s)Completed: 'Co"t �r1� 1 Well ID# t/ ft. 9.0 ft. Re.c3, `t
5a.Well Location: go ft. ^(0 ft. & CC1Q tx k
0SM F�t�i icier S ft. OC(�LJ ft. 2
Facility/Owner Name Facility ID#(if applicable) ft. ft. f" '- �•
L.
&io trr�.c-SS �� Di.�nc�:�r�-, �.7 7l_ ft. ft. t t� ": ✓ J
Physical Address,City,and Zip ft. ft. J U N 9 O Q 20 24
21.REMARKS
,`Its ;N �
County Parcel Identification No.(PIN) Ifrivt�-.G.::'D T'1'.r�‘ ,Y tMt
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifIf
• well field,ld one llaaC.11oong is sufficient) 22.Certification: /� n
J( 6 3c1.9U6efN 2VISS LICr. j(00q W 4S77t(`l � "C_�
6.Is(are)the well(s)'ermanent or DTemporary Signature o .enrfied Well Contractor Dam
�-�- By signing this form,I hereby certify well(s)that the was(were)constructed in accordance
7.Is this a repair to an existing well: _
Yes or I f c`o with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Ill!out known well construction information and explain the nature of the cops'of this record has been provided to the well owner.
repair under#21 remarks section or on the hack 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 I 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: g 49 0 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(4,200'and 2(d 100') construction to the following:
10.Static water level below top of casing: . (ft.) Division of Water Resources,Information Processing Unit,
(Twiner level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6# II& (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
_ �Y d above, also submit one copy of this form within 30 days of completion of well
E 12.Well construction method: r 1 t 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: rrj� 1636 Mail Service Center,Raleigh,NC 27699-1636
O 13a.Yield(gpm) Method of test: lt9ta/l ) IyLit 24c.For Water Supply&Injection Wells: In addition to sending the form to
r �y� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: I4 y 1"'1 Amount: la 62 completion of well construction to the county health department of the county
where constructed.
Forts GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016