GW1-2022-05753_Well Construction - GW1_20220606

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
1 En � ��' 1' Qt('� 14. ATER ZONES
FROM TO DESCRIPTION
NWellContractorNamet-�R ft. ft.
C-W. "'i'E 7I -73 t
NC Well Contractor Certification Number 15. UTER CASING(for multi-cased wells)OR LINER if a licable
' son i �_ FRO I TO DIAMETER THICKNESS MATERIAL
ft. ft. .Zs in. P `!!
Company Name It l..
16.INNER CASING OR TUBING( eothermal closed-loop)
2.Well Construction Permit#; 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
FRO TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
industrial/Comnercial wesidential Water Supply(shared) 18.QROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. ,
ti
Monitoring 13 Recovery
injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19. AND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) ]Tracer 20. RILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FRO TO DESCRIPTION(color,Hardness,soil/rock tv ft. e, rain size,etc.)
ft. � �t
4.Date Well(s)Completed: — Well ID# ft. ft.
Sa.Well Location:
ft. ft.
e,1 —'�4��r
Facility/Owner Name h C,FFaciillity iD#(if applicable)
��
Physical Address.City,and Zip I Ift. ft.
21. EMAIIKS
County I Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 22.Certification:
N W I
6.Is(are)the well(s)xpermanent or []Temporat•y r�15A
rtified Well Contractor Date
/'S ���,,,���aaa,,,,,,////// firm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes ar N0 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
IJYhis is a repair,Jill ant known well construction information n epolain the nature of'the ord 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:
A.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 I GW-1 is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: f SUOMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a4 For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(eraneple-3@200'and 2@100') construction to the following:
� )
1�.Static water Level below top of casing: (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: If I(in.) 24b�For Iniection Wells: In addition to sending the form to the address in 24a
�
12.Well construction method: /Q above,also submit one copy of this form within 30 days of completion of well
� 1`ETC r('
(i.e.auger,rota construction to the following:
g 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) (D Method of test: c 24ci For Water Supply& 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:b4k Amount: 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