GW1-2021-03150_Well Construction - GW1_20210625

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WELL CONSTRUCTION RECORD(M-11i For Internal Use Only:
1.Well Contractor Information:
?G. Wes , ( VIN 14.WATER ZONES
Well Contractor Namo FROM TO DESCREnION
��J �9�(a� 15 m CMG n. �K'EA tv4t' i5h4..
i'V L' ta.iC r S S oZ--rt-_ 3,itp'{��C j�'`Z;On fL �O k !"t;ti'c 0,01-( 94-4 trC$�
NC Wdl Contractor Ccrvacildon Number ��l l''�`�' Off;d� J is.ouTER CASING for mold-eased welts OR LINER ff liable
Amp-Punt�� \��� ��iKto FROM To DIAMETER TRICKNM I MATERIAL
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CotrtpaayName ft, �Cj tL q iu. �i`'* Pvc-
1&INNER CASING OR Tt1BING eothermar erosed-r
2.Well Construction Permit#: FROM I To I DIAMETER I THICRNFSa MATERIAL
L&I all applicable well construction permits(i.e.UIC County,State,Variance,etc.) it I tt in.
IL
3.Well Use(clheckwell use): 17. fw
Water Supply Well: FROM I TO I DIAMETER I SLOT SITE I TIUCKNiFSS I MATERIAL
Agricultural OMtmicipal/Public © ft of G tt A 'r to u(G Sc i�'{C3 4pWL
Geothermal(Heating/Cooling Supply) [Residential Water Supply(single) R to
lndustti il(Conunmial Residential Water Supply(shared) It GROUT
Irri - FROM I TO I MATMUAL EMPLACMUL TMETHOD&AMOUNT
Non-Water Supply Well: ® ft. .ZS IL ✓ � f�c.'R��
Monitoring . Recovery f4 tr
20jeetion Well: tL to
[A7q,mifer
ifer Recharge []Groundwater Remediation
19.5AND/GRAVEL PACK ratite
Storage and Recovery OSatinity Barrier FROM TO MATERIAL EMPLACEMEn METHOD
iTest QStora:waWDminage & &
erimental Technology QSubsidence Control R flt.
thermal(Closed Loop) QTMM X DRILLING LOG atach additional sheets ff s1M etc.)
thermal(HeatiD Conlin Return Other(explain under#21 Remarks FROM To DascRRrnTrox sake h.ren eaNreck la
ii O fL f U tt C4AJ 51W 6
4.Date Wdl(s)Completed: Co- 1- l Well lD# 10 ft /5 & de_ . si•fe w i SM41
5a.Well Location: IS rt 3S MS`4i*11� sietu - G%- 'i
Sokm lZ. �i Ntiii=TTE
3-5 tt l o
Facility/Owner Name Facility W#(ifappliablc) O fL 90 IL (Ste&y S+9�h Cd-F*-# r- wcty
�3 LSc< Qt114�f; Luca. RQ_ E)DE.,14 _o�C'.. ?9 3.2 0 R' /C o R ' . .' C-L4`f
Physical Address,City.and Zip n• R'
Ce J--U W A,N 21.REMARKS
County Parcel Identification No.(PIN)
S&Latitude and longitude In degreeshninutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 21 Certification:
O't 9 x "7�0• .( S 3 Cp /R W
6.Is(are)the wen(s)�Permaneut or Temporary Signature of Ceatited Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed In accordwice
7.Is this a repair to an eAsting well: []Yes or J@No with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the coN of this record has been provided to the u ell owner.
repair under#21 remark section or on the back of this form. 23.Site diagram or additional well details:
8.For GeoprobelDPT 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 ifnecessary.
drilled: sIIRMiTTAL INST CT;Q S
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9.Total well depth below land surface: /Ot7 (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For mrtltfple wells liar all depthi ifd(g'ero t(mwnple-3@200 and 201005 Construction to the following:
10.Static water level below top of seeing: (ft) Division
of Water Resources,Information Procusssing Unit,
Ifwater level is above casing,use"+° 1617 Mall Service Center,Raleigh,NC 27699-1617
7 Ta 14- '
11.Borehole diameter. .7 �& (in.) 24b.For Infection Wells: In kddition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
I2.Well construction method: M 6 'Rc T4 tZY construction to the following-
(i.e.auger•rotary,cable,direct push,etc.)
Division of water Resources,Underground Infection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Se i ice Center,Raleigh,NC 27699-1636
t I: TN •
139.Yield(gpm) as G p�� Method of test: _PP P 24e.For Water Ampty&Injection Wells: In addition to sending the form to
e.;AtC V V VV% the addresses) above, also I submit one copy of this form within 30 days of
13h.Dislnfeetion type: Amount: '/ oz_ completion of well constru f on to the county limith department of the county
where constructed
Fora GW-1 North Carolina Department of Environmental Quality-Division of Water Re 1 6urm Revised 2-22-2016
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