GW1-2021-00333_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
wI I I( Jy 14.WATER ZONESWell Contractor Namd
FROM TO DESCRIPTION
0 lY 3 ` d fc. �3 a ft. cwm Q Dt'
ft. IL
Q ft. Q Oc�_
NC Well Contractor Certification Number 15.OUTER CASING for mu cased'- `ells OR LINER if a lieable
1(�1 i1�' 1�(��f Dt/)(�( FROM TO DIAMETER THICKNESS MATERIAL
1� �\ I Yi1 \ ft. tag ft. in. S1)R vc'
Company Name
16.INNER CASING OR TUBING eotherntal closed-loo
2.Well Construction Permit#: �( FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC County,State, Variance,etc.) ft. Ct. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_1 Agricultural E)Municipal/Public ft. ft. in.
:)Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in•
Industrial/Commercial ID Residential Water Supply(shared)
18.GROUT,
h-ri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. I3 t
Monitoring DRecovery
Injection Well:
ft. ft.
__:Aquifer Recharge IDGroundwater Remediation
19.SAND/GRAVEL PACK if a licahlc '
_I Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_.Aquifer Test DStonnwater Drainage
ft. ft.
Experimental TechnologyISubsidence Control
Geothermal(Closed Loop) EIITracer 20.DRILLING LOG(attach additional sheets if necessar
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,eta)
BGeothermal(Heating/Cooling Return) I Other(explain under#21 Remarks) ft. 't ft. ,OI
4.Date Well(s)Completed: (� A� o Well ID# ft. 71 ft.
Sa.Well Location:
rc. 3 D tc.
vl'�k dot
Facility/O er Name Facility ID#(if applicable) O ft. ,aC' ft. Upo—w\ 1
3a1n Loikebour 0 VMS (L&3) L ft.
ft. ft.
Physical Address,City,and lip
ObC� 21.REMARKS I f•.:< _ .-.S F f'.i.I
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:
35° � It 1 ` 0 N FO I� ♦ o��� W T Iz Y � ;lii`I
U.,&" V v �-,L , 1 2 1-f t—�c I
6.Is(are)the well(s)0 Permanent or OTemporary Signature of tified Well C actor'; Date
By signing this form,1 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.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information IFexplain the nature of the copy of this record has been provided io 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 if necessary.
drilled: 2� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I 1 K l (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierew(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: U (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use'.+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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: MA6 U construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPL1Y�jWELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test: U 1 24c. For Water Supply&Iniection Wells: In addition to sending the form to
y� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1 I Amount: /r7� completion of well construction to the county health department of the county
where constructed.
f
t
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016