GW1-2021-00358_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information-
Lam � \11 NA it 14.WATER ZONES
Well Contractor Name
FROM TO DESCRIPTION
r ft ���r o� . ft. Vlln
ft. ft. i
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased.wells OR LINER if a licable
1�\-f D& I . 1�' ,/y`11�� FROM TO DIAMETER THICKNESS MATERIAL
\ �(l� yV L, 1 -}-\ ft. !�(D ft. in. �j o
Company Name IN l
(' ,'/�1 �//) 16.INNER CASING OR TUBING eolhcrmal closed-loop)
2.Well Construction Permit#: Vim°y V V OV O FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,State, Variance,etc.) ft. ft, in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:]Agricultural 6;2t..r 'pal/Public Q ft. �ft. in. 01 SL ;D �
:]Geothermal(Heating/Cooling Supply) den; l Water Supply(single) ft. ft. in.
-_Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
1tri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © ft. al®ft.
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft. ,
_ Aquifer Recharge In Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
__;
0 ft. 30 ft.
Aquifer Test �IStonnwater Drainage � �aC
Experimental Technology niSubsidence Control ft. ft.
Geothermal(Closed Loop) FnITracer 20.DRILLING LOG(attach additional sheets if necessary).
ElGeothermal(Heating/Cooling Return) 01Other(explain under#21 Remarks) FROM TO ft. DESCRIPTION(color,hardness,soil/rock a rain size,etc.)
^� vY ft. 0°
4.Date Well(s)Completed: iti 1 01� Well ID# ft. O ft.
5a.Well Location: ft. Or0 ft.
_J,/t 3 riY w e 1S ft- �l 7 ft. S
Facility/Owner Name Facility ID#(if applicable) a3ft ft. b1a f(/ Ck
(IA y\ k v A✓t \ ostbgn ft
v1 . ft. �w�
Physical Address,City,and Zip J ft. ft.
ul 3 11Pf1. 21.REMARKS
County ParcellIIdentificationONLo..((PINT)) l/ AM
pG1Ql i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 2
(if well field,one pla/lon�gjis-s�uffircient) 22.Certification:
��� eJ111 r 3 IJ N WAmm
6.Is(are)the well(s) ermanent or [)Temporary Signature of 41ified Well Co ctor tj"fl tiid"' Date
� / By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
�V
7.Is this a repair to an existing well: nYes or � with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 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./orm.
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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di.[Jerent(example-3@200'and 2 rJ100') construction to the following:
10.Static water level below top of casing: 49 (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: U (in.) 24b.For Infection Wells: In addition to sending the form 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: Yti l V 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: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: ,n 24c.For Water Suauly&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: �4 completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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