GW1-2021-02087_Well Construction - GW1_20210706

WELL CONSTRUCTION RECORD(GW-D For Internal Use Only:
1.Well Contractor Information:
Jit Ai
Well Contractor Name FROM TO DESCRIPTION
NC Well Contractor Certification Number OUTER CASIN43#or niulti4casitd.wolls)OR LINER(ifspolicable),
L FROM I TO DIAMETER THICKNESS MATERIAL
Company Name
.16.4 NNER CASI NG OR TUBI NG'i'tigeotheir rdil closed_luaovi.
2.Well Construction Permit#: of 3 FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County.State.Variance.etc.) ft. ft. in. PN[
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN'-:,
OAgricultural OMunicipal/Public FROM TO I DIAMETER I SLOTSIZE-1 THICKNESSMATERIAL
in.
oueothermal(Heating/Cooling Supply) 'AResidential Water Supply(single) ft. in.
0 Ind ustrial/Commercial DResidential Water Supply(shared)
7
Olnigation DWells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOVAT J
Non-Water Supply Well: n. CO f1. 130 _4_ out-e
OMonitoring ORecovery ft. ft.
Injection Well: ft. ft.
OAquifer Recharge OGroundwater Remediation
19.SAND/GRAXEL PACK(if applicable)
OAquifer Storage and Recovery OSalinity Barrier FROM I All) I MATERIAL E, FLA VVIENTMETHOD
OAquifer Test OStormwater Drainage T/A ft. I
ClExperimental Technology OSubsidence Control ft, ft. I
DGeothermal(Closed Loop) OTracer 26.4DRILLI QXOG(attach additionhLibecesif neccssary),`,,*
color,hardness,soil/rock t( yp e,g rain size,etc.)
OGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTIONft- _:j75 ft.
4.Date Well(s)Completed: Well ID# ft. 6-'t5- ft.
5a.Well Location: 4Q
R.
�"3hAAJ'< 00'2'r �D
bAf k P i5vA) f 61
Facility/Owner Name Facility ID#(if applicable) ft. ft.
95D lCROW 14 h deA-kr-yR4 N c ft, n.
Physical Address,City,and Zip it. ft.
'2 LREM ARKS
c 4 P_fe-e-,P_
County Parcel Identification No.(PIN) Infora-4fian Proce sing Unit
­ - I DWR Section
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field,one lattlong is sufficient) 22,Certification:
1'71.2,7 "N 74 0,3'Y',3 —W
6.Is(are)the well(s): &ermanent or 0'remporary SiOr'e of Certified Well Contractor Date
r','_'�Ining this form,/here4v certify that the wells)was(were)constructed in accordance with
1� 9
7.Is this a repair to an existing well: OYes or QqNo A NCAC 02C.0100 or 15A AfCAC 02C.0200 Well Construction Standards and that a copy
lfIlzis is a repair,fill out known well constriction inforntodon anNe'xplain the nature qJ'the of this record has been provided to the well owner.
repair under#2/remarks section or on the back of this forni. 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 construction info
construction,only I GW-I is needed, Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 6&9 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1620 (ft.)
Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths tidifferent(example-3@200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: L (ft.) information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
ll"water level Ly above casing,use­+" I
I].Borehole diameter: (in.) 24b.For Injection Well': Copy to DWR,Underground Injection Control(1­UC)
Program, 1636 MSC,Raleigh,NC 27649-1636
12.Well construction method: PS C A-*N P--4 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county—environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing ovJI00,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) _11-0 — Method of test: Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type 1C i, Amount: b o
�1fiallid_
Form GW-I North Carolina Deriarinient of Fnvimnnionta t r). r I—.--