GW1-2021-01988_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor InformeatLionl• 7M
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r I�C+T l.Y\ `T11
14.<WATER`ZONES. ". -'.j' ��� �•� ,:z� ` :���
FROM TO DESCREMOM
Well Contractor Name 2"�fe 29 i it. 3 M
y 3 + A 0 IL fL
NC Well Contractor Certification Number 15.'OUTER CASING for mul wells ORLIIVER
FROM TO DIAMETER TMCKNESS MATERIAL
U �(a A� s 5-3 fL
6 Utinj
Co any Name h
3 � 16.INNER GASING'ORTITBING otbermid
2.Well Construction Permit#: d 2 _1(� FROM TO DIAMETER IMC-ENESS I MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) L It. in.
3.Well Use(check well use): ft' R in.
Water Supply Well: 47.'SCREEN, _.,.'
FROM TO DIAMETER" SLAW SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public 0 & ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. &
Industrial/Commercial Residential Water Supply(shared)
,18.GROUT - - .
Irrigation FROM TO MATERIAL E31PI.ACEAMNT METHOD&AMOUNT
Non-Water Supply Well: ft. ft, C
Monitoring Recovery fL it.
Injection Well:
ftft
Aquifer Recharge Groundwater Remediation
"19.SA'ND/GRAVEVPACIC ifi'licable r`
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. .' EMPLACEMENT MEMOD
Aquifer Test [3Stormwater Drainage ft It.
Experimental Technology Subsidence Control fL &
Geothermal(Closed Loop) Tracer 20<DRILLING LOG'attach addititimil sheets ifneeess
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION color,haHness,soillroek type,gmin latt,do
S ) / IL it. Ste+ CA
4.Date Well(s)Completed: Well ID# IL J5 t,
59.Well Location: SZ R d O fL 6m ll 1 '-°
SalIED
MIL kcmcl MedlAa1 ft. ft AY 2 7 2021
Facility/Owner Name Facility ID#(ifapplicable) & ft
OPCG 1J" ('d. 1�bU(on JVC ft. ft ;iect
��;on
Physical Address,City,and Zip ft, IL
21'REMARKS
County Parcel Identification No.(PIN) L&I .AardfadL//'• S d L
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iattlong is sufficient) 22.Certification:
N W O 202!
6.Is(are)the well(s)OPermanent or 13Temporary ignature of Certified Well Contractor l5ate
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or �No with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the 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. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
F Total well depth below land surface: 5-or (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') Construction to the following:
/f
f Static water level below top of casing: q0 (ft) Division of Water Resources,Information Processing Unit,
water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276"-1617
i
11.Borehole diameter: (in.) 24b.For Iniection 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: construction to the following:
(i.e.auger,rotary,cable,detect push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: n 1636 Mail Service Center,Raleigh,NC 276"-1636
13s.Yield(gpm) 61) Method of test:_D�0�i�/ 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit Rohe copy of this form within 30 days of
13b.Disinfection type: Amount: 13 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016