GW1--00038_Well Construction - GW1_20231218

WELL CONSTRUCTION RECORD(G =1) For Internal Use Only: . ~
1.Well Contractor Information:
apt't1Ce.ra1LtY►S 14,WATER`-ZONES ' I' - .
Well Contractor Name FROM TO DESCRIPTION
4 a- 2afl re• 815 ft. I Gr'�
ft. ft. i
NC Well Contractor Certilicalion Number 15iOUTER:CASING:(for molti-egved;.svellifOR'LINER:(if'aD Liable)'
'EQ tow-i LULU F br 1 i i 1 rii •
FROM TO DIAMETER THICIINESS MATERIAL
0 ft' 11 to ft. it ii4- in. 5b12-o'i-I pv
Company Name
�1 .1 '•16ANNERCASINGOR-TUBING:(Re6thermelclosed-Ioop):, ...
Z.Well Construction Permit#: 262 3" 3 14 j i 7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(l.e.UIC County,State,Yariance,etc.) ft. . ft. j fn.
ft. ft. I la
3.Well Use(check well use):
Water Supply Well: FROMREEN i,;` ..
TO DIAMETER SLOTSIT.E THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft, hi.
Geothermal(Heating/Cooling Supply) `4:!Residential Water Supply(single) fc ft. in.
: Industrial/Commercial . )Residential Water Supply(shared) 1lk`GROUT_
• Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: . D ft. 20 ft. I4Dk.p1ui9 el rAV.i 11
Monitoring• DRecovery ft. R.
Injection Well:
ft. ft.
jAgaifer Recharge OGroundwater Remediation
19:SAND/GRAVEL PACK(Ifapplicable) .•<
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT RIETHOD
Aquifer Test • E3Stonnwater Drainage ft. ft. i
DExperimental Technology OSubsidence Control ft. ft.
OGeothermal(Closed Loop) °Tracer •,30 DR1LLING-LOG(eitacti additioaalalriet i if necessary)^-? ,
FROM TO DESCRIPTION(eobr,baldness,soiltsocktype,again size,eta)
riGeothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) ft. 20 ft. zji
4.Date Well(s)Completed:9 j'ato la 3 Weil Bo 314 i 17 24 ft• i a ft. 52..r1 Ovo.rbtt.r4Ln
5a Well Location: G7Q ft. j D I ft. w }harms Rock..
jimmy Ca(y-mharf hob f` itle ft &slid. (Zot_lr•, ;.s•;-, Sy.,,r"
Facility/Owner Name Facility ID#(if applicable) f P`� ' ..:+1--- fi 4^6'^.
165 ei A.14 UJhi. N tug , I.A.i c rt-su i Il es- Rs t,5 ft. ft. OF C 1 S 7021
Physical Address,City,and zip ryry M ft. ft.
ii 1 ',�3 't i i 1 1 x
i rv_d e 4re '11.-REMARKS REMARKS; It .. ti'Pr „•,:�J U1'11
County Parcel Identification No.(PIN) Qi e b>
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce ification:
35 3% 9q,075MJ N So ►1lp 1(0.75'7 w q j'Zl#123
6.Is(are)the well(s)16Permanent or Temporary igaetuse o stifled Well Contractor Date
By signing this form,I hereby certify that tine well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: {Yes or );No with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis.is a repair,fill out known well construction information and explain the nature of the copy of this record 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:
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
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: i SUBMH 1 AL INSTRUCTIONS!,
(ft) Y completion Total well depth below land surface: 31' 24a. For All Wells. Submit this form within 30 days of coal letion of well
For multiple wells list all depths ifdeerent(example-3@200'and 2@l00') construction to the following: !
10.Static water level below top of casing: (ft,) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Matt Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
�D t0.rt�1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: l construction to the following:
(i.e.auger rotary,cable,direct push,etc.)
Division of Water Resources,lUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service C
24 enter,Raleigh,NC 27699-1636
bu
13a.Yield(gpm) 3 Method of test: �i f c.For Water Snarly&Infection 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:Cu /Or t n oAmount: 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 Resource) Revised 2-22-2016