GW1--00249_Well Construction - GW1_20240105

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor Information:
•
Ke \i `l►' 'e.` 1L eco,Q t^-3-ac, h ..14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
6 D ft. ft.
L o e' (-), ft. it,
NC Well Contractor Certification Number
l • 15.OUTER CASING(for mull cased wells)OR LINER(if ap livable))
` o`\\\ `s eA Ut-A\ l'irN 9 +l FROM
TO D E ICKNESS MATERIAL
ft. 41✓ `6 fL 6' l - 'l s-- ?V C
Company Name
16.INNER CASING OR TUBING(geothermal closed loop).
2.Well Construction Permit#: 38C//i€) 3 5 FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction penults(l.e.UIC County.State,Variance,etc.) ft. ft. fa.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural OMunicipaVPublic ft. ft. in.
°Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft. ft. in. -
Olndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrigation 0Wells>100,000GPI) FROM TO MATERIAL ,- EMPLACEMENT ODhAMOUNT
`i
Non-Water Supply Well: /-°�ft. 2 c ' a on �
OMtmitoring ❑Recovery ft. ft.
Injection Well:
ft.DA ifer Rechargefc
qu ❑Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable)
°Aquifer Storage and Recovery °Salinity Barrier , FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test OStormwater Drainage ft. m
°Experimental Technology °Subsidence Control ft. ft.
°Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,Aatdaeas soinroektype groin sae,etc.)
0 ft. I,t7 it IGr-cs.� G Ac. _
4.Date Well(s)Completed: II iq 123 Well ID# (t, ft. 'Lb n• cIc4-p r)
5a.Well Location: :i 20t>ft' `300ft. b`\3P_ A
r)tt-N C'vt 5 G>74: CCi _d1 ft ft 7 .
Facility/Owner Name FacilitylD#(ifapplicable) ft. ft. 1 /''^
n ' � ii ij
14( f Z0 OV\INs \``4 ft. ft. J,4 At
ft. ft. J 1' tOZ4`
Physical Address,City,and Zip Ilk
,r a^,`
' S i>\. / •
3 6 822 21.REMARKS. .:.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) //'''��p� y 22.Certification:
'3 S r 1 OS N eco t 13 8 W e
.,1.4.1 _illajil_
6.Is(are)the well(s)://Permanent or °Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert(that the well(s)war(were)constructed In accordance with
7.Is this a repair to an existing well: °Yes or orNo iSA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
gilds(a a repair,fill out knownwell construction ifor maion and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of thls 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: 0 a (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list oil depths ifdifferent(example-3Qa 200'and 2®100')` 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static4 water level below top of casing: (it) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
t If water level is above casing.use"+"/
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(WC)` Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Pt t r'- I�C.)3tCk1 '{ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) / county environmental ,ealth 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) Method of test: k l~
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: ( H l Amount \ T 1 cY ,