GW1--06104_Well Construction - GW1_20241014

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. WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 1
Erie. G I '14.WATER ZONES I 7
Well Contractor Name ' FROM TO D1.SCRWTION
LI S 71 A 02Wft. 42?5" a CrOM
f. f.
NC Well Contractor Certification Number
IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIALCompany Name O u. (03 ft- to'i 'is S bQoZ Ric
f a/c
16.INNER CASING OR TUBING(geothermal closed400p)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.) 6 ft. 10 ft. 4 ;in. S c.+ y 0 1'v(
3.Well Use(check well use): It ft 11n
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
1 Agricultural I;OMunicipal/Public • ft, ft. to. i.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in. '
11 Industrial/Commercial D1 Residential Water Supply(shared) IS.GROUT
1 Irrigation FROM ' TO ' MATERAE 1 EMPLACEMENT METHOD-&AMOUNT
Non-Water Supply Well: O ft. 473 ft. 3L.Uk? % Poured 4- µ, rt �r
1 Monitoring DRecovery ft. ft. /� t ell1^-Q�6s�
Injection Well: o D. fro f- Arno ��C ^Sb L 6 e
1 Aquifer Recharge Groundwater Remediation OG •.7
19.SAND/GRAVEL PACK(if applicable)
*Aquifer Storage and Recovery QSalinity Barrier FROM ' TO MATERIAL EMPLACEMENT METHOD
•IAquifer Test 0Stormwater Drainage ft. ft. ,
ill Experimental Technology OSubsidence Control ft. ft. ' 1
(1 ....ertnal(Closed Loop) OTracer ,- 20.DRILLING LOG(attach additional sheets if necessary)
1111 Geothermal(Heating/Cooling Return) flOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type Praia size etc.)
J
^�/ d It ? It. Q .0
p
4.Date Well(s)Completed: 1-�-dq Well ID. Actlf.-2115 i 3 ft. 3Q ft'
ReA C.
5a.Well Location: 30 fr. 3vo f t. 6r1�V ICp L�� __
/� � (
'► `a.colJne., �Shirrt ., r '' ' TM �)
N ft. ft.
Facility/Owner Name Facility FDA(if applicable)
Ic07t �"�e_ Rd ko OC I 1 4 2024
�5�rlr,o n�
Physical Address,City,and Zipft ft.
O A 21.REMARK N~ `-"` 'C..,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
fl a
34:11 1 13. 27432 7SrAM 1. a'-Is& w G yS?7-14. 9-I6-ail
6.Is(are)the well(s)Irmanent or QI Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certifi,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well Ei Yes or ENo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known Hell con hurries iFffrlatelekff and eurpkia,the iratwroftle copy of this 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.IndicateTOTAL13UUMBER of wells construction details.You.may also attachadditionaipages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Ste) ft i'
eP ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 200'and 2@100') construction to the following:
10.Static water level below top of casing: 10 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+^1 1617 Man Service Center/Raleigh,NC 27699-1617
11.Borehole diameter: /6 (in) 241t.For Weals*Welts: Lw additiod to sending the€onn to the address in 24a
/� y above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: AiP' R-o-i-ckr construction to the following:
(ie.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: Q 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) oG Method of test: L7�Ott..1el e�/M4 24c.For Water Supply&Injection Wells: In addition to sending the form to
1 . the address(es)above,also submit one copy of this form within 30 days of
13b.Disinfection type: HI N Amount: I f 02. , completion of-well construction to the county health department of the county
where constructed. I I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016