GW1-2023-01740_Well Construction - GW1_20230213

WELL CONSTRUCTION RECORD(GA-1) For Internal Use Only:
1,Well Contractor Information:
7-In ACV1♦ 14.WATER ZONES -
F1t0.1t TO DESCRIPTION
Well Contractor Name VA
iL -7 s
_ s-2-.A rL fL Y1
NC Well Contractor Certification Number I&OUTER CASING for multi-cased
fwe!lls
11�MnNERR
ableFROi' TO 1AT
AL
y�"fLvC Company Nam: V 16.INNER CASING OR TUBING Wethertnol closed-loo
r� IATf17r:R TfnOMS 41ATERIAL
2.Well Construction Permit#:,PAS r 0 7 FROM TO D It
List all applicable well con true ion permits(Le.UfG Counh-,Slate,Variance,etc.)
IL n in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM To DIAh1ElI:R SLOT SIZE IMCIONESS MAT-VALI.
ElAgticultural ❑MunicipaUPublic 4 n 7 S'ft in• 4 t7 CiC
❑Geothermal(Heating/Cooling Supply) Ai Sidential Water Supply(Single) n ft. Im
❑lndustrial/Cothmcrcial ❑Residential Water Supply(shared) 18.GROUT
❑� tion ❑Wells>I00.000GPD MOM TO AIATIAIAL ZWLALCLMF.NTM1gIuoD6 AMtouNr
Non-Water Supply Well: R 10 n .«e 1 Pow
❑Monitoring ❑Reoovcry ---� n n• f
In)ectiou-Well: g rL
❑Aquifer Recbarge ❑Groundwater Remodiation
19.SANDIGRAVEL PACK Qf up disable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM Mt
To An�uAL F.WL,eCEMENT MtETOOD
❑Aquifer Test ` ❑Stermwater Drainage a Q R' 7 R. r (Q V
❑Experimental.Technology ❑Subsidence Control rt. ft
❑Geothermal(C)osed Loop) ❑Tracer 20.DRILLING LOG nttnch addidonDl sheets If becessa
FROM TO DESCRIPTION(co1q_r_bardutM wWrock type.grou etc
❑GeothermaI(Hcating(Coolin Return) ❑Otber(explain under#21 Remarks) / n it. S 4itA -C ve
4.Date Well(s)Completed: Well ID# R n -
R. ft.
5a.Well Location: -
�lnsh k,l� Gn 141 rU LOT .S-o rL fL -
Facility/Owner Nafne Facility lDN(if applicable)
rL n
u731 V1rginI on/ 't- �4• W1 "ST"'h IL rt. -
--, n n
Physical Address,City,and Zip
Z 7 4F 8 q 21.REAIARKS
County Peru[Identification No.(PK -
5b.Latitude and longitude in degrees/minutes/seconds or decl nal degrees:
(if well tleld,one latAong is sufficient) 22.Ce tendon:
33, C4011 IS N
Signature ofCer ified Well Contractor Dare
6.ls(are)the relf(s):�rmanent or pTemporary '
Bvsigning rhlr form,I hcrebv certifi that the hell(r)was(were)con lrucled in accordance with
7.IS this a repair to as ezislinE well ❑Yes or 15A NG1 C 02C.O10G or 15A,tiCAC 02C.0200 Well Cv rs uchor,Sea^lards and'hat a ceps
Ifthir is a repair,fill our brawn hell cvnabvcii0n i2/N0 information and explain the nature of the ojfh s record has been provided!o.he well owner.
repair under Hll remarks section or on the back ojlAis form. 23.Site diagram or additional well details:
S You may use the back of this page to provide additional well construction info
For t,eoprbbelDPT tie Closed-(oop Geotht3mnl Wells having the same
(add'Sec Over'in Remarks Box).'You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: �J 24.SUBMTTTAL INSTRUCI710NS
9.T tal well depth below land surface: / (ft) Submit this'GW-1 within 30 lays orwell completion per the followtng:
For multiple we1G list all depths ijdiiffvcnr(example-3Q200'and 2Q100�
24a. For A➢ Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
if%eater level.is above caring,toe"4"
6 % (�) 24b.For Injection Wells: Copy to DWK Underground Injection Control (fUQ
11.Borehole diameter:, d� program,1636 MSC,Raleigh,NC 27699-1636
12,Well cons ction method: f� �Y1T� 24c.For Water Supply and Clpen-Loop Geotbermsd Return Wells:Copy to the
tie.auger,rotaryr cable,dirut push,etc.) county environmental health department of the county where installed
FOR WATLI2,1SUPPLY WELLS ONLY- 24d.For Water Wells producirt over 100 00D GPD: Copy to DWR,CCPCUA
{� Permit Program,1611 MSC,Ralcigb, C 27699-1011
13a.Yield(gpm) !/y 1liethod of test: I'1
13b.Disinfection type: C \ Amount. 3 OZ-
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised lr 2018