GW1-2023-01486_Well Construction - GW1_20230209

r rrtin r Urrrt
WELL CONSTRUCTION RECORD (GW-1) For Tnternal Use Only.
1.Well Contractor Information:
J V� 0 t" I 14,WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft.
ft, ft.
NC We`
Contractor Certification Number 15.OUTER CASING thowr multi-cased we)h OR LINER f ir lleable
Cn ra J I = �k FROM TO DIAMETE1t T[irCKNE56 MATER]AL_
t� � 1 r tt, ft, ln. 0 lT�_
Company Name j -
i �C w 16 R CASING OR TUBING eothermai closed-loop)
2.Well Construction Permit#: 1 1 ` FROM TO DIAMETER Inmu tNESS MATERUL
List all applicable well construction permits(i.e.UIC County.Stale, Variance,etc.) ft. ft.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREENrRO,, To DiAMETER SLOT SUM THICKNESS nfATERIAL
Agricultural DMunicipal/Public fl, g, ln.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft,
Industrial/Commercial C)Residential Water Supply(shared) 18,GROUT
hri tion FROM TO MATE EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well: ft. tt.
Monitoring ORecovery ft. ft.
Injection Well: —
Aquifer Recharge aGroundwater Remediation ft. ft.
19.SANDIGRAVEL PACK if a Ilcablet
Aquifer Storage and Recovery DSalinity Barrier FROAf TO MATERfA[_ EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage it, ft
Experimental Technology DSubsidence Control
GeothenTial(Closed Loop) Tracer 20.DRILS.ING LOG attach additional sheets If necessary
Geothermal(Heating/Cooling Return) Other(ea lain under#21 Remarks) FROM TO DESCRIPTION color,hardn ;Wrock e,Ulfil size,etc.)
�l b ft. ft. ,
4.Date Well(s)Completed; 5 - Well ID# J IL
Sa.Well Location:
ft. ft.
r ran Z ft. ft. _ n
Facility/Ow=44arae
,^ �n`�^p FaacilityJD#(if
^�applicable) ft. ft. _ �[� �} Q 2Q2J
410 U it I`� �tCY•;C�Q� l�f 1p�a� �' aye, ft, ft. —
Physical Address,City,and Zip ft, ft,
O,1r 4 N I ?. 21.REMARKS _
County Parcel Identification No.(PK
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s)dPermanent or Temporary Signature of C ell Cont&ctor Date
By signing this form,I hereby certify thra'the uvIl(s)iws(Awre)constructed in accordmrce
7.Is this a repair to an existing well: C]Yes or [JNo wilh 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and drat u
Ifthis is a repair,fill out known null construction information and explain the nature of the copy of this reeord has been provided to if a vell owner.
repair under#11 remarks.ruction or on the back of this form.
23.Site diagram or additionsl well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page-:o 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: f SUBMITTAL INSTRUCTIONS
l
9.Total well depth below land surface: M/ (ft.) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2(a_';100� construction to the following:
10.Static water level below top of caslog: �� (ft.) Division of Water Resources,information Processing Unit,
If water level is above casing,use' 1617 Mail Service Center,Raleigh,NC 27699-1617
1I.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: r 1 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: ff 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)T� _ Method of test: 'U 24c.For Water Supply&iolectil a Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
131b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
t:n.,,,nw_i n.,.:..:......f11T.....D_­..., D-. _d 11—