GW1-2022-06478_Well Construction - GW1_20220701

WELL CONSTRUCTION RECORD (GW-1) r Internal Use Only:
( 1.Well Contractor Information: (, \
14. ATER ZONES
Well Contractor Name FRCM TO DESCRIPTION
�+
N C`,�` 430
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER(if a licable)
FR M TO DIAMETER TH[ KNESS MATERIAL
ft. Q / ft. 26 in. G
Company Name (7 a'C)
16. NNER CASING OR TUBING eothermal clos d-too )
2.Well Construction Permit#: FR TO DIAMETER THI KNESS 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 THMMETHODI
Agricultural Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft it in
Industrial/Coimnercial Residential Water Supply(shared) 18. ROUT
lri ation FRO TO MATERIAL EM LACE
Non-Water Supply Well:
r-
Monitoring Recovery
Injection Well: ft ft.
Aquifer Recharge Groundwater Remediation
19.SANDIGRAVEL PACK(if a licable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stonnwater Drainage
Experimental Technology Subsidence Control
RGeothermal(Closed Loop) 1ITracer 20.1 IRILLING LOG(attach additional sheets if nee ssar )
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) FRO TO DESCRIPTION(color,ha dness,soil/rock type,grain size,etc.)
ft. r ft.
4.Date Well(s)Completed: Well ID# r ft. IC ft.
5a.rWeellll Location: c7 tft
lS .
l�lil� N
Facility/Owner NIme Facility ID#(if applicable) ft.
fL ft.
Physical Address,City,and Zip
21. EMARKS
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:
N W t
`tT
6.Is(are)the well(s) Permanent or Temporary Sig at re of Certified Well Contractor Date
By 'g aing this Jorna, I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: n Yes or No with 1 A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
#'this is a repair,fill out known well construction infaTnation t explain the anata e of the co o'this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Si a 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
construct`on,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 SUBMITTAL INSTRUCTIONS
,�hr_ It9.Total well depth below land surface: o�UIU (ft.) 24a. or All Wells: Submit this form within 30 days of completion of well
For uandtiple wells list all depths if defJerent(example-3 a 200'and 2@100') construction to the following:
10.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: �Q (in.) 24b. For Injection 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: A 1 R ' )4 constriction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Di ision of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Aft C.JU Method of test: 24c.for Water Supply&Injection 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: Imo& Amount: compl tion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Qual ty-Division of Water Resources Revised 2-22-2016