GW1--07629_Well Construction - GW1_20231204

..x..Iuu IL.v,..o1rk.v%.,iiMr1ItE ..,viwll..TVV-il k or Internal Use Only: I
1.Well Contractor Information:(� /f N
•
``.e w.14, 17e.� 1 ' '. 1 1,-1 ,e..(i ks 14:WATER ZONES t .i:: - .
Well ConttuctorName FROM TO DESCRIPTION
6® ft: ft. 1
‘2.6-6‘) �i Cl,ltta IL
NC Well Contractor Certification Number 1"S.COUTER CASING`foi multi-cased wells OR LINER f a l(cable
�� �►t� ` a 1.��` �,vk 1 `� FROM TO DIAME R THICKNESS MATERIAL :: ..
1V` VV 5i
Company Name �- 1 ft.
fL 6, [7in. I j2 S pe.N�
16:SINNER:CASING�ORTUBING(geothermaldosed=loop) `1 -
2.Well Construction Permit#: (✓i4 N-W C- 2 62 3--0D i Lei FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC County,State,Variance,etc.) ft. ft 1is
t 3.Well Use(check well use): • fu fu a, in.
Water Supply Well: 17:SCREEN
v FROM. TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. It ;in.
, OGeothermal(Heating/Cooling Supply) i2Residential Water Supply(single) ft. ft. 1,in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) .:18sGROUT ;r ., ' .
❑irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL • EMPLACEMENT ETHOD&AMOUNT
Non-Water Supply Well: 0 ft. )44 ft. e
❑Monitoring ORecovery ft. ft. ( �` �`1
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑A uifer Storage and Recovery ❑Salmi Barrier "19:SAND/GRAVEL PACK(if applicable):::: _-`_-:,,' .:.-:-. ::'; -:_•;
q g tY FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonmwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer :•20;DRILLING LOG(attach additional sheers ifnecessery)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soiUrocktroe plain size etc.)
0 f. ID ft' -r��6-. 1e.y,
4.Date Well(s)Completed: I i 12 12j Well ID# /6 fL -26 ft- p'trott c.., �, ,r,1 4e.
5a.Well Location: / 2� " t .)1, e(Ai-frft. ft. V •
Facility/OtvnerName ft./� Facility lD#(if applicable) f D•
405 �id)r% kJ y ft. ft. .- -_,
Physical Address,City,and Zip , ft. ft. , .4'a. ..^''t.--r: t^r 4,..
•C-Ct t7L71t-r-t) s 2I:REMARKSS_ _ 'OrC 0 .' 2o2J' •
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,.•,'; „-
(if well field,onene lat/loong is sufficient) 22.Certification: '
e
„Lisa/l 1CI N (30159 S.`1 W ,‘4 r
,1,11 tra..._
6.Is(are)the well(s): iiDPermanent or ❑Temporary Signature of Certified Well Connector Date
By signing this form.I hereby certify that the well(s)was(were)constructed in accordancewith
7.Is this a repair to an existing well: ❑Yes or go)No 1SA NCAC 02C.0100 or 1SA NCdC 02C.0200 Well Construction Standards and that a copy
If this Is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
, repair under#21 remar/s section or on the back of this form. 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
/
9.Total well depth below land surface: Lib b (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3®200'and 2C4100)
' e 1.
(�) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: �
, (flutter level is above casing,use"+•• t Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1
if 11.Borehole diameter: in.)
24b.For Injection Wells:Copyito DWR,Underground Injection Control(IUC)
A Program,1636 MSC,Raleigh,NC 27699-1636
-
12.Well construction method: 1- 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 over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) p Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 141- 9'4 I `` '' Method of test: 1 P'�
Amount: 1 plivic